Medi-Cal Update

Pharmacy | October 2018 | Bulletin 930

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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.

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.

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
October 1, 2018 BUPRENORPHINE/NALOXONE Strengths added drugs cdl p1a (27)
November 1, 2018 ONDANSETRON Restriction changed, restriction removed drugs cdl p1c (16)
November 1, 2018 QUETIAPINE FUMARATE Restriction removed drugs cdl p1c (43)
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2. Ostomy Medical Supplies No Longer Contracted

Effective for dates of service on or after January 1, 2019, the ostomy HCPCS billing codes have the following updates:

Providers may refer to the Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet for the specific HCPCS billing code policy.

Reminder:

A written prescription (or electronic equivalent) signed and dated by the recipient's physician is required. A recipient's need for the item must be reviewed annually by a physician. The HCPCS billing code on the claim must be appropriate for the medical supply item dispensed.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
mc sup (1)
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3. Buprenorphine Extended-Release Injection Added as a Pharmacy Benefit

Effective for dates of service on or after October 1, 2018, the buprenorphine extended-release injection is available as a pharmacy benefit when provided by a specialty pharmacy and with an approved Treatment Authorization Request (TAR).

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

Provider Manual(s) Page(s) Updated
Pharmacy physician (1)
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4. MAPC Established for Assist Devices and Peak Flow Meters for Inhalers

Effective for dates of service on or after December 1, 2018, the Department of Health Care Services establishes a maximum allowable product cost (MAPC) for covered assist devices (spacers and aerochambers) and peak flow meters intended for use with metered dose inhalers. The MAPC is the price on file for the products that meet the medical supply descriptions and that are currently available within Medi-Cal’s pharmacy claims processing system. There is no change to claim quantity limits.

Medical Supply Description MAPC
Inhaler, Assist Devices (spacer, bag or reservoir [with or without mask] for use with metered dose inhaler) $31.33
Peak Flow Meters, Non-Electronic $15.76

The Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet is updated to reflect this change. Providers may refer to the Medical Supplies section of the appropriate Part 2 manual for detailed policy information.

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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.

Changes, effective April 1, 2017
NDC Labeler Code Contracting Company's Name
51267 NALPROPION PHARMACEUTICALS
   
Changes, effective May 15, 2018
NDC Labeler Code Contracting Company's Name
00074 ABBVIE INC.
   
Changes, effective July 1, 2018
NDC Labeler Code Contracting Company's Name
15054 IPSEN BIOPHARMACEUTICALS, INC.
   
Terminations, effective October 1, 2018
NDC Labeler Code Contracting Company's Name
00062 ORTHO MCNEIL PHARMACEUTICALS
00064 HEALTHPOINT, LTD.
00149 WARNER CHILCOTT PHARMACEUTICALS INC.
00300 TAP PHARMACEUTICALS INC
00535 FOREST LABORATORIES
10158 GSK CONSUMER HEALTHCARE HOLDINGS (US)LL
11701 COLOPLAST CORPORATION
15749 AMERICAN ANTIBIOTICS, INC.
15821 FOCUS LABORATORIES, INC.
43595 ANGELINI PHARMA, INC.
44946 SANCILIO & COMPANY, INC.
46026 GLOUCESTER PHARMACEUTICAL INC.
46987 ACTAVIS KADIAN LLC
49158 THAMES PHARMACEUTICALS, INC.
49685 NEUROGESX, INC.
50192 NAUTILUS NEUROSCIENCES, INC.
50816 NEW AMERICAN THERAPEUTICS
55390 BEDFORD LABORATORIES
55607 HEALTH SCIENCE FUNDING, LLC
58487 NEW HAVEN PHARMACEUTICALS, INC.
59075 ELAN PHARMACEUTICALS, INC./ATHENA NEURO
62250 BELCHER PHARMACEUTICALS, LLC
62794 MYLAN BERTEK PHARMACEUTICALS, INC.
67467 OCTAPHARMA PHARMAZEUTIKAGM
68209 OCTAPHARMA A.B.
68405 PHYSICIAN THERAPEUTICS LLC
68453 VICTORY PHARMA, INC
68669 VISTAKON PHARMACEUTICAL LLC
69036 SALLUS LABORATORIES, LLC
69150 BIOMES PHARMACEUTICALS, LLC
69158 GLENVIEW PHARMA, INC
69171 MERRIMACK PHARMACEUTICALS, INC.
70147 GLENDALE INC.
70688 KASTLE THERAPEUTICS, INC.
70882 CAMBRIDGE THERAPEUTIC TECHNOLOGIES, LLC
71399 AKRON PHARMA INC.
75989 ACTON PHARMACEUTICALS

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 (2–7, 9–12, 14, 16–20)
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6. 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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7. Upcoming Pharmacy Fee-For-Service 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. 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 provide updates in the upcoming months on how these claim adjustments will roll 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 provider events, as well as implementation updates.

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8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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