Medi-Cal Update

Pharmacy | September 2018 | Bulletin 928

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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 IRINOTECAN LIPOSOME Drug added, administration added, restrictions added drugs cdl p1b (46)
July 1, 2018 LAMIVUDINE/ TENOFOVIR DISOPROXIL FUMARATE Drug added, administration added, restriction added drugs cdl p1b (50)
July 1, 2018 LANREOTIDE ACETATE Drug added, administration added, restrictions added drugs cdl p1b (51)
July 20, 2018 IVOSIDENIB Drug added, administration added, restrictions added drugs cdl p1b (48)
July 24, 2018 DARUNAVIR/ COBICISTAT/ EMTRICITABINE/ TENOFOVIR ALAFENAMIDE Drug added, administration added, restrictions added drugs cdl p1a (52)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
May 15, 2018 RITONAVIR Restriction changed, administration added drugs cdl p1c (49)
July 1, 2018 HEPATITIS B VIRUS VACCINE Strength added drugs cdl p1b (33)
October 1, 2018 PAZOPANIB HYDROCHLORIDE Restriction added drugs cdl p1c (23)
November 12, 2018 LOMUSTINE Restrictions added drugs cdl p1b (60)
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2. Alert: Mandatory Use of CURES 2.0 Begins October 2, 2018

A new DUR Educational Article titled “Alert: Mandatory Use of CURES 2.0 Begins October 2, 2018” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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3. 2018 Immunization Updates: Flu, Tdap, HepB, Zoster, MMR, Adult Vaccines

A new DUR Educational Article titled “2018 Immunization Updates: Flu, Tdap, HepB, Zoster, MMR, Adult Vaccines” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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4. Updates to the List of Contracted Diabetic Test Strips and Lancets

Effective for dates of service on or after January 1, 2019, newly contracted products are added to the List of Contracted Diabetic Test Strips and Lancets. In addition, the maximum acquisition cost (MAC) and maximum allowable product cost (MAPC) for some currently contracted products are updated.

Effective for dates of service on or after January 1, 2019, blood ketone test strips, urine ketone test strips and urine ketone/glucose combination test strips are Code I items, restricted for use in the detection of diabetic ketoacidosis in beneficiaries with a documented diagnosis of diabetes. Claim quantities without authorization are limited as follows:

To view products' Code I requirements and quantity limits, providers may refer to the Medical Supplies section of the appropriate Part 2 manual. The Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet is also updated to reflect this information.

Effective for dates of service on or after April 1, 2019, products deleted from the List of Contracted Diabetic Test Strips and Lancets are no longer eligible for reimbursement. The manufacturers no longer guarantee a MAC for the deleted products.

Note:

LifeScan, Inc. OneTouch ULTRA test strips, all package sizes, are no longer reimbursable after December 31, 2019.

Reminders:
Reimbursement for contracted diabetic lancets and test strips is the MAPC of the item (price on file) plus the appropriate professional dispensing fee. These items are reimbursable only for pharmacy providers. Reimbursement is restricted to items in the List of Contracted Diabetic Test Strips and Lancets. The manufacturers have guaranteed the purchase of the contracted products at or below the MAC, upon request, for dispensing to eligible fee-for-service Medi-Cal beneficiaries.

Blood glucose test strips and lancets are Code I items, restricted to beneficiaries being treated by a physician for a diabetes diagnosis documented in their medical records.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
mc sup (1–4, 7–12)
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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.

Additions, effective October 1, 2018
NDC Labeler Code Contracting Company's Name
00990 ICU MEDICAL INC.
36000 BAXTER HEALTHCARE CORPORATION
65628 CUTISPHARMA, INC.
69536 FOUNDATION CONSUMER HEALTHCARE, LLC
70010 GRANULES PHARMACEUTICALS, INC.
70255 ARRAY BIOPHARMA INC.
70621 BIOFRONTERA INC.
71045 ACHAOGEN, INC.
71104 BIOVERATIV US LLC
71334 AGIOS PHARMACEUTICALS, INC.
71428 GLASSHOUSE PHARMACEUTICALS LLC
71930 EYWA PHARMA
76336 HRA PHARMA AMERICA INC.
   
Terminations, effective October 1, 2018
NDC Labeler Code Contracting Company's Name
15310 CREEKWOOD PHARMACEUTICAL, INC.
24477 EKR THERAPEUTICS, INC.
24486 ARISTOS PHARMACEUTICALS, INC.
58181 NEXTSOURCE BIOTECHNOLOGY, LLC
58604 SPROUT PHARMACEUTICALS, INC.
69051 PROFOUNDA, INC.
69654 AYTU BIOSCIENCE, INC.

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 (5, 7, 8, 12, 15, 18–20)
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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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