MedicaidCoverageMedium impact
Provider Bulletin 11-19-2025 Medi-Cal Rx Pharmacy Benefits and Cell and Gene Therapy Coverage DHCS APL 25-013 IE LA SAC SD
Molina Healthcare·CA · Hematology, Oncology, Family Medicine +2 more·Medical Policy
Effective date
Jul 1, 2025
We identified it
Jun 19, 2026
Summary
Molina Healthcare California updated guidance on Medi-Cal Rx pharmacy benefits and introduced coverage for advanced cell and gene therapies (LYFGENIA™ and CASGEVY™) under a federal access model. Key changes include clarification that outpatient drugs are covered by Medi-Cal Rx while Molina continues managing physician-administered drugs, and specific billing instructions for the new gene therapies.
Action Required
Immediately: Billing team must ensure LYFGENIA™ and CASGEVY™ claims are submitted through Medi-Cal FFS, NOT billed to Molina. Update billing system to flag these therapies for FFS submission. For Provider Administered Drugs (PADs), continue following Molina policies and use Availity Essentials portal for claims and prior authorization management. Coordinate with care teams to assist eligible members in accessing gene therapies through DHCS-approved treatment centers.