Medi-Cal Update

Pharmacy | November 2017 | Bulletin 908

Print Medi-Cal Update
 

1. Medi-Cal List of Contract Drugs

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

A summary of drugs that have been 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.

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
December 1, 2017 PROMETHAZINE WITH PHENYLEPHRINE AND CODEINE Restriction added drugs cdl p1c (36)
December 1, 2017 SEVELAMER HYDROCHLORIDE Restriction added drugs cdl p1d (2)
Print Article | Return to Top
 

2. Correction: NDC Labeler Code for UCB PHARMA, INC.

The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section incorrectly listed UCB PHARMA, INC. with NDC labeler code 50458. The correct NDC labeler code is 50474.

The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section is updated to reflect the correct NDC labeler code.

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

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
Expanded Access to Primary Care Program
General Medicine
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Multipurpose Senior Services Program
Obstetrics
Pharmacy
Rehabilitation Clinics
drugs cdl p5 (10)
Print Article | Return to Top
 

3. Protection Plus Contour Brief, X-Large, Erroneously End-Dated

The product by Medline Industries, Inc., Protection Plus Contour Brief, X-Large, billed under HCPCS code T4524 (adult sized disposable incontinence product, brief/diaper, extra large, each) with Universal Product Number (UPN) 40080196291763 was erroneously end-dated May 31, 2015. Any claims with dates of service on or after June 1, 2015, that were denied for code T4524, UPN 40080196291763, due to an invalid UPN will be reprocessed. No action is required of providers.

Print Article | Return to Top
 

4. Updates to the List of Enteral Nutrition Products and Policy Clarifications

Effective for dates of service on and after January 1, 2018, newly listed enteral nutrition products are eligible for reimbursement and newly specified maximum acquisition cost (MAC) and estimated acquisition cost (EAC) for certain products applies.

The manufacturers guarantee providers can purchase the listed products at or below the MAC, upon request, for dispensing to Medi-Cal fee-for-service outpatient recipients. Refer to the Enteral Nutrition Products section of the manual for the MAC price suppliers' phone numbers.

The criteria outlined in the Enteral Nutrition Products section of the provider manual was updated to provide clarification for certain product types and to remove certain restrictions for products with probiotics, effective for dates of service on or after December 1, 2017.

Effective for dates of service on or after June 1, 2018, products deleted from the List of Enteral Nutrition Products will no longer be reimbursable, even with an approved TAR or SAR. The MAC for these products is no longer guaranteed.

Note:

Listing of a product is not a guarantee of its availability. The product number approved on an authorization must be the same product number dispensed to the recipient and claimed for reimbursement by the provider.

Recipients affected by these changes, should seek new prescriptions from their physician and new authorizations from their pharmacy provider for a comparable product on the List of Enteral Nutrition Products. Continuing care does not apply.

Medi-Cal recipients denied enteral nutrition products who believe the denial was in error, may ask for a state hearing by contacting the California Department of Social Services at 1-800-743-8525 or 1-855-795-0634, or by sending a written request to:

California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, California  94244-2430

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
enteral (7, 9–11, 13, 14, 16, 17)
Print Article | Return to Top
 

5. New Pharmacy Provider Self-Attestation Process Starting January 2018

The Department of Health Care Services (DHCS) will be implementing a new provider self-attestation process in January 2018 for Pharmacy providers seeking the higher of two professional dispensing fees as part of the upcoming reimbursement changes related to covered outpatient drugs. DHCS will be providing additional details in upcoming Medi-Cal Updates, including:

DHCS received approval from the Centers for Medicare & Medicaid Services (CMS) for State Plan Amendment (SPA) 17-002, which modifies Medi-Cal's payment methodology for covered outpatient drugs. Included as part of those changes is the reimbursement for the professional dispensing fee, which will change from its current structure to a two-tiered structure depending upon a pharmacy's total annual claim volume. Providers should refer to the Pharmacy Reimbursement Project web page on the DHCS website for additional information on this project.

Print Article | Return to Top
 

6. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

Print Article | Return to Top


Note:

If you cannot view the MS Word or PDF (Portable Document Format) documents correctly, please visit the Web Tool Box to link to a download site for the appropriate reader.