MedicaidAdministrativeHigh impact
26-641 Submit Medi‑Cal Rx and Fee‑for‑Service Carved‑Out Medication Claims Correctly
Health Net·CA·Pharmacy
Effective date
Jul 27, 2026
We identified it
Jun 20, 2026
Summary
Effective July 27, 2026, Health Net will begin denying claims for carved-out medications that should be billed to Medi-Cal Rx (pharmacy claims) or Medi-Cal Fee-for-Service (medical/institutional claims) instead of Health Net. Billing teams must identify carved-out medications and route them to the correct Medi-Cal payer to avoid denials.
Action Required
Before July 27, 2026: Billing team must identify all carved-out medications using DHCS resources and update billing system routing to send pharmacy claims to Medi-Cal Rx and medical/institutional claims with carved-out medications to Medi-Cal Fee-for-Service instead of Health Net. Review the Medi-Cal Rx Pharmacy Carve-Out Scope Document to determine which medications are affected. Claims billed incorrectly to Health Net will be denied and require resubmission to the appropriate Medi-Cal payer.