Pharmacy Rx PA Universal Form

The California Department of Managed Health Care (DMHC) is requiring all health plans, risk-bearing organizations, physicians, and physician groups to use a new standardized two-page Prescription Drug Prior Authorization Request form, Form 61-211, for Medi-Cal members by January 1, 2015.

In preparation for this change, IEHP is requiring its providers to use the new form beginning November 3, 2014.

This change will not affect Medicare members enrolled in the IEHP DualChoice Cal MediConnect Plan and Medicare DualChoice (HMO SNP) Plan.

Frequently Asked Questions (FAQ):

  1. What will happen to the IEHP Pharmacy Exception Request Forms (PER)?

    IEHP PER forms will change on November 3, 2014.  Providers must use the new Prescription Drug Authorization Request Forms for Rx prior authorization requests.

  2. How long do health plans and insurers have to make a determination of coverage?

    DHCS requires that a response to the Rx prior authorization request must be made within 1 business day.

  3. What happens if the form is not filled out correctly or in its entirety?

    IEHP will deny Rx prior authorization requests if the new form is not filled out completely or does not include all the information necessary to make a sound determination.

  4. Where can providers go for more information?

    Visit the IEHP Formulary page on our Provider website for more information such as the Formulary Tool.

Please see links below for additional supporting items:

Universal - Prescription Drug Prior Authorization (Rx PA) Form for Medi-Cal Members
IEHP Formulary
PA Drug Treatment Criteria