Medi-Cal Update

Pharmacy | December 2017 | Bulletin 910

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1. Medi-Cal List of Contract Drugs

The following provider manual sections 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 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
November 1, 2017 ACALABRUTINIB Drug added, administration added, restriction added drugs cdl p1a (2)
December 4, 2017 DOLUTEGRAVIR/RILPIVIRINE Drug added, administration added, restriction added drugs cdl p1a (62)
January 1, 2018 ABEMACICLIB Drug added, administration added, restriction added drugs cdl p1a (1)
January 1, 2018 GLECAPREVIR/PIBRENTASVIR Drug added, administration added, restriction added, notes added drugs cdl p1b (28)
January 1, 2018 VARICELLA ZOSTER VACCINE Drug added, administration added, restriction added drugs cdl p1d (28)

Changed Drug(s)

Effective Date Drug Summary of Changes Page(s) Updated
May 1, 2017 LISDEXAMFETAMINE DIMESYLATE Administration added drugs cdl p1b (57)
October 1, 2017 SONIDEGIB Restriction changed drugs cdl p1d (6)
January 1, 2018 NORELGESTROMIN AND ETHINYL ESTRADIOL Restriction removed, strength added drugs cdl p1c (7)
January 1, 2018 ZOSTER VACCINE Restriction changed drugs cdl p1d (34)
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2. Authorized Drug Manufacturer Labeler Codes Update

The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section has been updated as follows.

Additions, effective January 1, 2018
NDC Labeler Code Contracting Company's Name
50268 AVPAK
59353 VIFOR (INTERNATIONAL) INC.
60219 AMNEAL PHARMACEUTICALS
70436 SLATE RUN PHARMACEUTICALS, LLC
70709 CYCLE PHARMACEUTICALS, LTD.
70785 IRONWOOD PHARMACEUTICALS, INC.
70801 FLEXION THERAPEUTICS, INC.
70842 MELINTA THERAPEUTICS, INC
71093 ACI HEALTHCARE USA, INC.
75826 WINDER LABORATORIES, LLC

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, 13, 19, 20)
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3. Updates to the List of Enteral Nutrition Products

Additional updates have been made to the List of Enteral Nutrition Products per the Updates to the List of Enteral Nutrition Products and Policy Clarifications article published in the November 2017 Medi-Cal Update.

Effective for dates of service on or after January 1, 2018, products are added to the List of Enteral Nutrition Products.

Effective for dates of service on or after June 1, 2018, products are deleted from the List of Enteral Nutrition Products.

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4. Erroneous Treatment Delays and Denials for HIV PrEP and PEP

The Department of Health Care Services (DHCS) has recently been made aware of incidents of erroneous treatment delays and denials for HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) used to prevent seroconversion to HIV. These incidents have negatively impacted beneficiary health. In most of the identified cases the cause for delay/denial of a service was a basic lack of information/understanding related to the scope of benefits and/or claims processes involved with billing for the service.

For Medi-Cal beneficiaries enrolled in a Managed Care Plan (MCP), PrEP and PEP medications are noncapitated. These medications are billed and reimbursed as Medi-Cal fee-for-service claims for both MCP and fee-for-service beneficiaries. When used as a preventative regimen for people at risk of acquiring HIV (PrEP) or for post-exposure treatment, these medications do not require a Treatment Authorization Request (TAR) as DHCS understands the consequence of delaying or denying access to these life-altering medications.

Many of the delays and denials involve pharmacies in the MCP networks not dispensing PrEP and PEP and pharmacy staff incorrectly informing beneficiaries that PrEP and PEP are not benefits of Medi-Cal. There have also been reports of medical providers misinforming patients that PrEP treatment is not a benefit, therefore refusing to issue a prescription for the medications, and instructing patients to use condoms along with traditional safe sex practices.

DHCS encourages timely access, as delays in access to these medications may have deleterious health effects for beneficiaries, including seroconversion from HIV negative to HIV positive. It is the responsibility of pharmacy providers, medical providers and ancillary staff to be fully informed about the scope of benefits and the proper submission of claims for noncapitated drugs. DHCS requests that all Medi-Cal providers, both MCP and fee-for-service, review the scope of benefits associated with drugs used to prevent the transmission of HIV. DHCS encourages providers to take appropriate actions to ensure that all ancillary staff are equally well informed regarding the scope of benefits and the processes and procedures for providing and billing for the medications when it is medically necessary.

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5. Pharmacy Provider Self-Attestation Mailer Arriving Early January 2018

In the second week of January 2018, fee-for-service Medi-Cal pharmacy providers should receive a mailer. This mailer features important information regarding the upcoming claim volume attestation for providers seeking the higher of two professional dispensing fees as part of the forthcoming reimbursement changes for covered outpatient drugs. The URL to the online attestation portal that goes live mid-January 2018 will be included, as well as a unique login ID and password to access the portal.

Note:

Most chain pharmacies will not receive the mailer because most chain pharmacies are coordinating attestations via a corporate point-of-contact.

As has been published in previous Medi-Cal Updates, the Department of Health Care Services (DHCS) is implementing a new fee-for-service reimbursement methodology for covered outpatient drugs. Part of this new methodology is a two-tiered professional dispensing fee based on a pharmacy provider’s total (Medi-Cal and non-Medi-Cal) annual pharmacy claim volume ($13.20 if fewer than 90,000 claims per year; $10.05 if 90,000 or more). Reporting the claim volume is a self-attestation process, which will be submitted electronically and must be done annually.

Note:

DHCS policy is that a claim is equivalent to a dispensed prescription; therefore, the attestation is for the total dispensed prescription volume.

Only fee-for-service Medi-Cal providers dispensing fewer than 90,000 total prescriptions per calendar year are eligible to receive the higher of the two professional dispensing fees and must complete this attestation in order to receive it.

The attestation period for both the 2016 and 2017 calendar years will be open from January 15, 2018, to February 28, 2018. Separate attestations must be submitted for each calendar year. The web portal will close at 12 a.m. on March 1, 2018, and attestations will not be accepted after that time. The attestation for each calendar year reporting period will determine the professional dispensing fee component of the pharmacy claim reimbursement for claims with dates of service within the State’s following fiscal year. As an example, a 2017 calendar year claim volume attestation will determine the professional dispensing fee for claims within the State’s 2018 – 2019 fiscal year (dates of service from July 1, 2018, through June 30, 2019).

For additional information, providers can refer to the Pharmacy Provider Self-Attestation FAQs or the Pharmacy Reimbursement Project web page on the DHCS website. For inquiries not covered in either, providers may call the Telephone Service Center at 1-800-541-5555 and select Option 4 then Option 2.

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6. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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