Medi-Cal Update

Pharmacy | May 2017 | Bulletin 896

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1. Medi-Cal List of Contract Drugs

The following provider manual section(s) have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs, Drugs: Contract Drugs List Part 2 – Over-the-Counter Drugs and Drugs: Contract Drugs List Part 4 – Therapeutic Classifications.

A summary of drugs that have been added or changed is shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

Added Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
April 1, 2015 IBRUTINIB Drug added, Administration added, Restriction added drugs cdl p1b (36)
April 1, 2017 TENOFOVIR ALAFENAMIDE Drug added, Administration added, Restriction added drugs cdl p1d (11)


Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
April 7, 2017 LEDIPASVIR/
SOFOSBUVIR
Restriction changed drugs cdl p1b (50)
April 7, 2017 SOFOSBUVIR Restriction changed drugs cdl p1d (4)
May 1, 2017 APREPITANT Restriction added drugs cdl p1a (14)
May 1, 2017 INFLUENZA VIRUS VACCINE Restriction added drugs cdl p1b (40)
May 1, 2017 LAPATINIB Restriction added drugs cdl p1b (50)
May 1, 2017 LISDEXAMFETAMINE DIMESYLATE Restriction removed drugs cdl p1b (57)
May 1, 2017 MENINGOCOCCAL GROUP B VACCINE Restriction changed drugs cdl p1b (63)
June 1, 2017 NORETHINDRONE AND MESTRANOL Restriction added drugs cdl p1c (10)
June 1, 2017 NORGESTIMATE AND ETHINYL ESTRADIOL Administration added drugs cdl p1c (10)
June 1, 2017 OMEPRAZOLE/SODIUM BICARBONATE Restriction removed drugs cdl p1c (14)
June 1, 2017 ONDANSETRON Restriction removed drugs cdl p1c (14)
July 1, 2017 ABACAVIR SULFATE/
DOLUTEGRAVIR/
LAMIVUDINE
Restriction added drugs cdl p1a (1)
July 1, 2017 ABIRATERONE ACETATE Restriction added drugs cdl p1a (1)
July 1, 2017 ADO-TRASTUZUMAB EMTANSINE Restriction added drugs cdl p1a (3)
July 1, 2017 AFATINIB Restriction added drugs cdl p1a (3)
July 1, 2017 ATAZANAVIR/
COBICISTAT
Restriction added drugs cdl p1a (16)
July 1, 2017 ATAZANAVIR SULFATE Restriction added drugs cdl p1a (17)
July 1, 2017 BEVACIZUMAB Restriction added drugs cdl p1a (22)
July 1, 2017 BOSUTINIB Restriction added drugs cdl p1a (24)
July 1, 2017 CABAZITAXEL Restriction added drugs cdl p1a (28)
July 1, 2017 CABOZANTINIB
S-MALATE
Restriction added drugs cdl p1a (28)
July 1, 2017 CERITINIB Restriction added drugs cdl p1a (34)
July 1, 2017 COBICISTAT Restriction added drugs cdl p1a (45)
July 1, 2017 COBICISTAT/
DARUNAVIR
Restriction added drugs cdl p1a (45)
July 1, 2017 CRIZOTINIB Restriction added drugs cdl p1a (47)
July 1, 2017 DABRAFENIB Restriction added drugs cdl p1a (49)
July 1, 2017 DARATUMUMAB Restriction added drugs cdl p1a (52)
July 1, 2017 DASATINIB Restriction added drugs cdl p1a (53)
July 1, 2017 DEGARELIX Restriction added drugs cdl p1a (54)
July 1, 2017 DELAVIRIDINE MESYLATE Restriction added drugs cdl p1a (54)
July 1, 2017 DOLUTEGRAVIR Restriction added drugs cdl p1a (62)
July 1, 2017 ELOTUZUMAB Restriction added drugs cdl p1b (2)
July 1, 2017 ELVITEGRAVIR Restriction added drugs cdl p1b (2)
July 1, 2017 ELVITEGRAVIR/
COBICISTAT/
EMTRICITABINE/
TENOFOVIR ALAFENAMIDE
Restriction added drugs cdl p1b (2)
July 1, 2017 EMTRICITABINE/
RILPIVIRINE/
TENOFOVIR ALAFENAMIDE
Restriction added drugs cdl p1b (3)
July 1, 2017 EMTRICITABINE/
TENOFOVIR ALAFENAMIDE
Restriction added drugs cdl p1b (3)
July 1, 2017 ERLOTINIB Restriction added drugs cdl p1b (8)
July 1, 2017 ETRAVIRINE Restriction added drugs cdl p1b (13)
July 1, 2017 FENTANYL Restriction changed drugs cdl p1b (16)
July 1, 2017 FULVESTRANT Restriction added drugs cdl p1b (24)
July 1, 2017 GEFITINIB Restriction added drugs cdl p1b (27)
July 1, 2017 HYDROMORPHONE Restriction changed drugs cdl p1b (35)
July 1, 2017 IDELALISIB Restriction added drugs cdl p1b (37)
July 1, 2017 INDINAVIR SULFATE Restriction added drugs cdl p1b (39)
July 1, 2017 IPILIMUMAB Restriction added drugs cdl p1b (44)
July 1, 2017 LAPATINIB Restriction added drugs cdl p1b (50)
July 1, 2017 MORPHINE SULFATE Restriction changed drugs cdl p1b (73, 74)
July 1, 2017 NIVOLUMAB Restriction added drugs cdl p1c (7)
July 1, 2017 OBINUTUZUMAB Restriction added drugs cdl p1c (11)
July 1, 2017 OFATUMUMAB Restriction added drugs cdl p1c (12)
July 1, 2017 OLAPARIB Restriction added drugs cdl p1c (12)
July 1, 2017 OSIMERTINIB Restriction added drugs cdl p1c (15)
July 1, 2017 OXYCODONE HCL Restriction changed drugs cdl p1c (17)
July 1, 2017 PALBOCICLIB Restriction added drugs cdl p1c (18)
July 1, 2017 PANOBINOSTAT Restriction added drugs cdl p1c (19)
July 1, 2017 PEMBROLIZUMAB Restriction added drugs cdl p1c (22)
July 1, 2017 RALTEGRAVIR Restriction added drugs cdl p1c (39)
July 1, 2017 RILPIVIRINE Restriction added drugs cdl p1c (42)
July 1, 2017 RITUXIMAB Restriction added drugs cdl p1c (43)
July 1, 2017 SAQUINAVIR MESYLATE Restriction added drugs cdl p1d (1)
July 1, 2017 TIPRANAVIR Restriction added drugs cdl p1d (17)
July 1, 2017 TRABECTEDIN Restriction added drugs cdl p1d (19)
July 1, 2017 TRAMETINIB Restriction added drugs cdl p1d (19)
July 1, 2017 VENETOCLAX Restriction added drugs cdl p1d (27)
July 1, 2017 VORINOSTAT Restriction added drugs cdl p1d (28)
July 1, 2017 ZIV-AFLIBERCEPT Restriction added drugs cdl p1d (31)
August 1, 2017 MALATHION Restriction added drugs cdl p1b (61)
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2. Enteral Nutrition Product List Update

Effective for dates of service on or after June 1, 2017, Epic4Health.com has added a new package size for its Sol Carb Specialized Modular Carbohydrate enteral nutrition product. The change is from a 227 gram container to a 454 gram container. The Medi-Cal billing number will remain the same (52766000701) with the UPC Number (Case) changing. The 227 gram container is still available selectively in the market place until supplies are depleted. The MAC per gram remains the same.

The amount reimbursed to providers for contracted enteral nutrition products is the estimated acquisition cost (EAC) listed on the List of Enteral Nutrition Products spreadsheet plus a 23 percent markup.

Listing items is not a guarantee of an item's availability. Product numbers approved on a Treatment Authorization Request (TAR) must be the product number dispensed to the beneficiary and be the product number claimed for reimbursement by the provider. Billing quantities must be appropriate for the product size (quantity) dispensed and product description on the List of Enteral Nutrition Product spreadsheet. Rounding quantities on claims for enteral nutrition products is not permitted.

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3. Prescription Written by a Physician is Required for Medical Supplies

Effective for dates of service on or after July 1, 2017, claims for covered medical and incontinence supplies and enteral nutrition products provided upon a prescription are eligible for reimbursement only if the prescription is written by a physician. Title 42 Code of Federal Regulations (CFR) 440.70 requires Medicaid programs only reimburse providers for medical supplies and enteral nutrition products that are ordered by a physician. In addition, the regulation requires a recipient's need for medical supplies be reviewed by a physician annually.

This information is reflected in the following provider manual(s):

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
General Medicine
Long Term Care
incont (1)
Durable Medical Equipment
Pharmacy
enteral (1, 4, 10, 15, 16); incont (1); mcsup (1)
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4. Drug Safety Communication: Risks of Codeine and Tramadol Use in Children

A new DUR Educational Article titled “Drug Safety Communication: Risks of Codeine and Tramadol Use in Children” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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5. HIV Drug Treatment Policy Clarification

In order to prevent unnecessary delays in treatment, the Department of Health Care Services (DHCS) wishes to clarify the use of the word “treatment.”  When used to describe the Code I restriction on agents used to treat Human Immunodeficiency Virus (HIV), the use of the word “treatment” refers to individuals with a positive HIV test as well as those prescribed the medication for post-exposure prophylaxis (PEP) of HIV.

For information about HIV prescription covered products and program coverage, refer to the Drugs: Contract Drugs List Part 1 section of the Medi-Cal Pharmacy provider manual.

For an explanation of Code I restriction language, providers should refer to the Drugs: Contract Drugs List Introduction section of the Medi-Cal Pharmacy provider manual.

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6. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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