Medi-Cal Update

Pharmacy | August 2018 | Bulletin 926

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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 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
July 1, 2018 EFAVIRENZ/ LAMIVUDINE/ TENOFOVIR DISOPROXIL FUMARATE Drug added, administration added, restriction added drugs cdl p1b (1)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
January 2, 2018 BRIGATINIB Administration added, note added drugs cdl p1a (24)
August 1, 2018 DESOGESTREL AND ETHINYL ESTRADIOL Restriction changed drugs cdl p1a (54)
August 1, 2018 DROSPIRENONE/ ETHINYL ESTRADIOL/ LEVOMEFOLATE CALCIUM Restrictions changed drugs cdl p1a (65)
August 1, 2018 ESTRADIOL VALERATE/ DIENOGEST Restrictions changed drugs cdl p1b (11)
August 1, 2018 ETHYNODIOL DIACETATE AND ETHINYL ESTRADIOL Restriction changed drugs cdl p1b (13)
August 1, 2018 LEVONORGESTREL AND ETHINYL ESTRADIOL Restriction changed drugs cdl p1b (55)
August 1, 2018 NORETHINDRONE Restriction changed drugs cdl p1c (8)
August 1, 2018 NORETHINDRONE ACETATE AND ETHINYL ESTRADIOL Restriction changed drugs cdl p1c (8)
August 1, 2018 NORETHINDRONE AND ETHINYL ESTRADIOL Restriction changed drugs cdl p1c (9)
August 1, 2018 NORETHINDRONE AND MESTRANOL Restriction changed drugs cdl p1c (10)
August 1, 2018 NORGESTIMATE AND ETHINYL ESTRADIOL Restriction changed drugs cdl p1c (11)
August 1, 2018 NORGESTREL AND ETHINYL ESTRADIOL Restriction changed drugs cdl p1c (11)
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2. Changes to Pharmacy and Compound Drug Pharmacy Claim Forms

Pharmacy Claim Forms 30-1 and 30-1C, as well as Compound Drug Pharmacy Claim Forms 30-4 and 30-4C, are being updated. Below are the relevant dates pertaining to these updates:

Providers can order the new forms starting August 24, 2018, by using the Provider Forms Reorder Request and notating “New” next to the quantity. During the transition period, providers can still order the old version of the forms by notating “Old” next to the quantity. Forms can also be ordered by calling the Telephone Service Center at 1-800-541-5555. For instructions on how to complete the Reorder Request, providers may refer to the Forms Reorder Request: Pharmacy section of the Pharmacy provider manual.

Changes to the forms are as follows:

New 30-1 and 30-1C Pharmacy Claim Forms:

New 30-4 and 30-4C Compound Drug Pharmacy Claim Forms:

Note that, due to the addition of two new fields to the forms, claim line 4 has been removed from forms 30-1 and 30-1C. Additionally, ingredient line numbers 24 and 25 were removed from forms 30-4 and 30-4C.

For instructions on how to properly bill using pharmacy claims, refer to the completion and examples sections in the appropriate Part 2 manual.

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

Provider Manual(s) Page(s) Updated
Acupuncture
Chiropractic
Long Term Care
Adult Day Health Care Centers
AIDS Waiver Program
Expanded Access to Primary Care Program
Heroin Detoxification
Hospice Care Program
Multipurpose Senior Services Program
oth hlth (5)
Audiology and Hearing Aids
Chronic Dialysis Clinics
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Home Health Agencies/Home and Community Based Services
Inpatient Services
Local Educational Agency
Medical Transportation
Obstetrics
Orthotics and Prosthetics
Psychological Services
Rehabilitation Clinics
Therapies
Vision Care
cal child bil guide (1); oth hlth (5)
Pharmacy cal child bil guide (1); cal child bil ph (2, 4); compound comp (2, 6–16); compound ex (2–6); iv sol spec (4); medi cr ph (6, 13, 14); medi cr ph ex (6, 7, 10–17); oth hlth (5); pcf30-1comp (2, 7–16); pcf30-1ex (2–7); pcf30-1sub (2); pcf30-1tips (1, 2, 4); share ph (2–6)
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3. Enteral Nutrition Product-Specific Criteria Removed for Kate Farms, Inc.

Effective for dates of service on or after July 1, 2018, the product-specific criteria restricting the newly added Kate Farms, Inc. products to tube-feeding only and requiring documentation of intolerance or severe allergy to other products does not apply. To be eligible for Kate Farms, Inc. products, beneficiaries must meet the medical criteria for the specific product category in the Enteral Nutrition Products section of the appropriate Part 2 manual. The List of Enteral Nutrition Products is updated to reflect this change.

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 beneficiary and claimed for reimbursement by the provider.

Medi-Cal beneficiaries 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 (855) 795-0634, or by sending a written request to the following address:

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

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4. Updates to the List of Contracted Tracheostomy Supplies

Effective for dates of service on and after September 1, 2018, several products are added to the List of Contracted Tracheostomy Supplies. In addition, the maximum acquisition cost (MAC) and maximum allowable product cost (MAPC) for certain tracheostomy products are updated.

Effective for dates of service on or after January 1, 2019, certain products and Universal Product Numbers (UPNs) are deleted from the List of Contracted Tracheostomy Supplies and are no longer reimbursable. The MAC for products deleted from the list is no longer guaranteed by RGH Enterprises Inc. (dba Independence Medical).

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5. Authorized Drug Manufacturer Labeler Codes Update

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

Terminations, effective July 1, 2018
NDC Labeler Code Contracting Company’s Name
63032 STIEFEL LABORATORIES

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 (14)
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6. Upcoming Pharmacy Fee-For-Service Reimbursement Changes for Covered Outpatient Drugs

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. Although the policy effective date mandated by the Centers for Medicare & Medicaid Services (CMS) is April 1, 2017, it will take the state's Fiscal Intermediary additional time to update the claims processing system to reimburse using the new methodology. DHCS anticipates that the system changes will be implemented in late 2018. After system implementation, DHCS intends to make retroactive adjustments for all claims with dates of service between the policy effective date of April 1, 2017, and the date of system implementation. DHCS will engage stakeholders in the upcoming months with regards to how these claim adjustments will be rolled out.

As outlined in California's State Plan Amendment 17-002 approved by CMS on August 25, 2017, the new reimbursement methodology reflects the following changes:

Pharmacy providers are reminded that until such time that DHCS implements the new fee-for-service reimbursement, the pharmacy dispensing fee shall be reimbursed according to the previous methodology ($7.25 retail or $8 for Long Term Care pharmacies). This includes the dispensing fee submitted for 340B drug claims by covered entities and their contract pharmacies pursuant to Welfare and Institutions Code (W&I Code), Section 14105.46.

Providers should refer to the Pharmacy Reimbursement Project page on the DHCS website for access to additional project resources, including the General Project FAQs. DHCS strongly encourages the Medi-Cal pharmacy fee-for-service provider community to closely monitor upcoming Medi-Cal Update pharmacy bulletins for additional information regarding any future stakeholder events, as well as implementation updates.

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7. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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