Medi-Cal Update

Pharmacy | May 2018 | Bulletin 920

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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 2 – Over-the-Counter Drugs.

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
June 7, 2018 SODIUM FLUORIDE Drug changed to
over-the-counter
drugs cdl p2 (18)
June 7, 2018 VITAMINS A, D AND C WITH SODIUM FLUORIDE Drug changed to
over-the-counter
drugs cdl p2 (19)
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2. Pharmacist Furnishing of Medications under Statewide Protocol

All medications authorized by Senate Bill 493 and subsequent amendments of the Business and Professions Code (B&P Code), Section 4052 are reimbursable by the Medi-Cal program for pharmacy claims, including drug costs and dispensing fees, when furnished by pharmacists within their scope of practice. Pharmacists do not need to be enrolled as Ordering, Referring and Prescribing (ORP) providers when they are the prescriber on record using their own National Provider Identifier (NPI) for these claims.

The following medication classes are currently exempt from ORP enrollment for reimbursement of pharmacy claims, including drug costs and the dispensing fees, when furnished by pharmacists within their scope of practice:

When the Department of Health Care Services (DHCS) implements reimbursement for the professional services associated with furnishing the above medication classes, as authorized under Assembly Bill 1114 and Welfare and Institutions Code (W&I Code), Section 4132.968, the pharmacist providing such services must be an approved ORP provider. Additionally, all pharmacists furnishing medications under collaborative practice agreements according to B&P Code, Sections 4052.1, 4052.2 and 4052.6 will be required to be ORP providers in order for pharmacy claims to be reimbursed. Therefore, DHCS encourages all pharmacists to become ORP providers with the Medi-Cal program.

Providers should refer to the Ordering, Referring and Prescribing (ORP) web page on the Medi-Cal website for more information.

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3. New Manual Section Added for PADs Reimbursable as Pharmacy Benefits

The Department of Health Care Services (DHCS) Pharmacy Benefits Division (PBD) has introduced a new section in the Pharmacy Provider Manual. This section has been added to enable providers to more easily identify Physician Administered Drugs available through the Pharmacy Benefit.

This new section lists the drug products and units of measure for medications that are given/administered/implanted/inserted by physicians or other qualified medical practitioners and are available and billable as pharmacy benefits. Unless otherwise indicated, an approved Treatment Authorization Request (TAR) is required for reimbursement. Pharmacy claims in this section are billed using the product National Drug Code (NDC).

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

Provider Manual(s) Page(s) Updated
Pharmacy physician (1–3)
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4. Contracted Incontinence Absorbent Product Updates and Policy Reminders

Effective for dates of service on or after June 1, 2018, one protective underwear product from First Quality Products, Inc. is added to the List of Contracted Incontinence Absorbent Products and the HCPCS code for one disposable underpad product from Medline Industries, Inc. is changed.

In addition, the item numbers for two products from Cardinal Health 200, LLC are changed.

Effective for dates of service on or after August 1, 2018, certain products from Cardinal Health 200, LLC, Drylock Technologies, Ltd., First Quality Products, Inc. and San Pablo Commercial Corporation are deleted from the List of Contracted Incontinence Absorbent Products and are no longer reimbursable. The maximum acquisition cost (MAC) for products deleted from the list is no longer guaranteed by the manufacturer.

The Department of Health Care Services (DHCS) reminds providers that only incontinence medical supplies ordered by a physician are reimbursable, pursuant to Code of Federal Regulations (CFR), Title 42, Section 440.70. In addition, a recipient’s need for incontinence medical supplies must be reviewed by a physician annually.

Providers are also reminded that incontinence products supplied as refills are reimbursable if the product remains reasonable and necessary and the existing supply is nearly exhausted. To ensure that refilled incontinence medical supplies remain reasonable and necessary, providers should contact the recipient prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the recipient.

In addition, providers are reminded that selecting the appropriate product size to accommodate the recipient’s body type and mass may optimize a better fit and reduce leakage, thereby decreasing the number of product changes. A proper fit may also contribute to the comfort of recipients and the prevention of excess product folds that may cause pressure.

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5. Updates to the List of Enteral Nutrition Products and Policy Additions

Effective for dates of service on or after July 1, 2018, products by the following manufacturers are added to the List of Enteral Nutrition Products:

The manufacturers guarantee providers can purchase the listed products at or below the maximum acquisition cost (MAC), upon request, for dispensing to Medi-Cal fee-for-service outpatient recipients. Refer to the Enteral Nutrition Products section of the appropriate Part 2 manual for the MAC price suppliers’ telephone numbers.

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.

Effective for dates of service on or after July 1, 2018, Vitaflo is discontinuing the following Flavor Pac products and they will no longer be reimbursable:

Product Label Name Billing Number
Flavor Pac Black Currant 50600-0541-59
Flavor Pac Lemon 50600-0540-98
Flavor Pac Orange 50600-0541-11
Flavor Pac Raspberry 50600-0541-35
Flavor Pac Tropical 50600-0541-73

Vitaflo has also removed the Universal Product Code (UPC) item number for the specialized product, Renastart, and updated the case number to 812539021490.

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, MS 9-17-37
Sacramento, CA  94244-2430

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
enteral (17)
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6. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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