Medi-Cal Update

Pharmacy | July 2017 | Bulletin 900

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1. Medi-Cal List of Contract Drugs

The following provider manual section(s) has been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs.

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 Drugs
Effective Date Drug Summary of Changes Page(s) Updated
August 1, 2017 MORPHINE SULFATE/NALTREXONE Drug added, restriction added, administration added, strength added drugs cdl p1b (74)

Changed Drugs
Effective Date Drug Summary of Changes Page(s) Updated
May 1, 2017 ENZALUTAMIDE Restriction added drugs cdl p1b (5)
May 30, 2017 TRASTUZUMAB Strength added drugs cdl p1d (20)
June 12, 2017 MARAVIROC Administration added,
strength added
drugs cdl p1b (61)
July 19, 2017 RALTEGRAVIR Strength added drugs cdl p1c (39)
August 1, 2017 DUTASTERIDE Restriction removed drugs cdl p1a (65)
August 1, 2017 MOMETASONE FUROATE MONOHYDRATE Restriction added drugs cdl p1b (72)
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2. Medical Supplies: Sterile Needles Restricted to a New Contract List

Effective for dates of service on or after November 1, 2017, claims billed with HCPCS code A4215 (needles, sterile, any size, each) will be restricted to products on the new List of Contracted Sterile Needles (HCPCS A4215) spreadsheet. These products will no longer require documentation of the product cost (an invoice, manufacturer catalog page or price list), as an attachment to the claim for reimbursement. The new manual sections and the new spreadsheet will be published for providers in the August 2017 Medi-Cal Update.

DHCS recently signed a maximum acquisition cost (MAC) agreement with RGH Enterprises, Inc. (dba Independence Medical) for products that meet the HCPCS code A4215 description, including pen needles used in conjunction with injection pens to deliver insulin. The MAC agreement is a guarantee from Independence Medical that any Medi-Cal provider can purchase the products upon request at or below the MAC for dispensing to Medi-Cal fee-for-service outpatient recipients.

Effective for dates of service on or after November 1, 2017, claims billed with HCPCS code A4215 will require the Universal Product Number (UPN) and UPN Qualifier as published on the list.

The maximum allowable product cost (MAPC) for the sterile needles on the list will be the same as the contracted MAC as published on the list. The maximum amount reimbursed to providers will be the lesser of:

Reimbursement for sterile needles is subject to the Upper Billing Limit defined in California Code of Regulations (CCR), Title 22, Section 51008.1. The UPN on the claim billed must be the exact UPN for the product dispensed. Listing of contracted products does not guarantee the product’s availability.

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3. Enteral Nutrition Product List Update

Effective for dates of service on or after August 1, 2017, Polycal, unflavored, 400g can, will be reimbursable with an approved authorization on the Medi-Cal Fee-For-Service List of Enteral Nutrition Products. This product, manufactured by Nutricia North America, is a powdered concentrated source of energy and is available as a specialized enteral nutrition product. Please refer to the List of Enteral Nutrition Products for billing and UPC numbers. The EAC price is 0.0214.

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 an authorization 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 Products spreadsheet. Rounding quantities on claims for enteral nutrition products is not permitted.

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