Medi-Cal Update

Pharmacy | November 2018 | Bulletin 932

Print Medi-Cal Update
 

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
September 17, 2018 DORAVIRINE Drug added, administration added, restrictions added drugs cdl p1a (64)
September 17, 2018 DORAVIRINE/ LAMIVUDINE/ TENOFOVIR DISOPROXIL FUMARATE Drug added, administration added, restrictions added drugs cdl p1a (65)
October 1, 2018 BINIMETINIB Drug added, administration added, restrictions added drugs cdl p1a (23)
October 1, 2018 ENCORAFENIB Drug added, administration added, restrictions added drugs cdl p1b (4)
October 15, 2018 DACOMITINIB Drug added, administration added, restrictions added drugs cdl p1a (51)
October 31, 2018 MOXETUMOMAB PASUDOTOX-TDFK Drug added, administration added, restrictions added drugs cdl p1b (78)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
December 1, 2018 RIMEXOLONE Restriction added drugs cdl p1c (48)
January 1, 2019 COLCHICINE Administration added, restriction added drugs cdl p1a (48)
February 1, 2019 COLCHICINE Administration changes, restriction added, note added drugs cdl p1a (48)
Print Article | Return to Top
 

2. Naloxone HCl Available to Bystanders At Risk of Witnessing Opioid Overdose

Effective for dates of service on or after October 1, 2018, naloxone HCl is a covered pharmacy benefit for Medi-Cal beneficiaries at risk of experiencing an opioid overdose and for beneficiaries at risk of witnessing an opioid overdose as a bystander. This policy is consistent with California Civil Code, Section 1714.22, and applies to pharmacy claims submitted under the order of a licensed prescriber or when naloxone HCl is furnished by pharmacists under the statewide protocol pursuant to California Business and Professions Code, Section 4052.01.

Further information about pharmacists furnishing naloxone HCl to Medi-Cal beneficiaries under statewide protocol can be found in an article titled “Pharmacist Furnishing of Medications under Statewide Protocol” in the May 2018 Medi-Cal Update.

Print Article | Return to Top
 

3. Buprenorphine Extended-Release Injection Authorized by Specialty Pharmacy

Effective for dates of service on or after October 1, 2018, the buprenorphine extended-release injection is available as a pharmacy benefit through a select network of authorized pharmacies with an approved Treatment Authorization Request (TAR).

The address and contact information of the current network pharmacy authorized to provide this benefit are listed below:

Avella Specialty Pharmacy
2288 Auburn Boulevard, Suite 102
Sacramento, CA  95821-1619

Telephone: 1-888-792-3888
Fax: 1-888-554-3299

For more information regarding the buprenorphine extended-release injection pharmacy benefit, providers may refer to the Physician-Administered Drugs section in the Pharmacy manual.

Print Article | Return to Top
 

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)
Print Article | Return to Top
 

5. Next Pharmacy Provider Self-Attestation Starts January 2019

This article provides information regarding the 2018 calendar year claim volume attestation to fee-for-service Medi-Cal pharmacy providers seeking the higher of two professional dispensing fees for fiscal year 2019 – 2020. These additional details include:

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 (Medicaid and non-Medicaid) annual pharmacy claim volume ($13.20 if less than 90,000 claims per year; $10.05 if 90,000 claims or more). Reporting claim volume is a self-attestation process, submitted electronically.

Note:

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

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

The attestation period for calendar year 2018 will be open from January 15, 2019, through February 28, 2019, and will determine the professional dispensing fee component of pharmacy claim reimbursement for claims with dates of service from July 1, 2019, through June 30, 2020 (the state’s following fiscal year). The web portal closes at 11:59 p.m. on February 28, 2019, and attestations will not be accepted after that time.

In early January 2019, enrolled fee-for-service Medi-Cal pharmacy providers will receive a mailer that contains the URL for the online attestation portal, as well as a unique login ID and password. Providers should note that most chain pharmacies will not receive the mailer because corporate offices are coordinating attestations for their pharmacies via a home office point of contact.

DHCS received approval in late August 2017 from the Centers for Medicare & Medicaid Services (CMS) for State Plan Amendment 17-002, which modifies Medi-Cal’s payment methodology for covered outpatient drugs. Included as part of those changes is the amount of the professional dispensing fee, which will change from its current structure to a two-tiered structure depending upon a pharmacy’s total annual claim volume. Providers should refer to the Pharmacy Reimbursement Project page on the DHCS website for additional information on this project.

Print Article | Return to Top
 

6. 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.

Print Article | Return to Top
 

7. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

Print Article | Return to Top


Note:

If you cannot view the MS Word or PDF (Portable Document Format) documents correctly, please visit the Web Tool Box to link to a download site for the appropriate reader.