Medi-Cal Update

Pharmacy | December 2018 | Bulletin 934

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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, Drugs: Contract Drugs List Part 2 – Over-the-Counter 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
October 1, 2018 CEMIPLIMAB-RWLC Drug added, administration added, restrictions added drugs cdl p1a (36)
January 1, 2019 NETARSUDIL Drug added, administration added drugs cdl p1c (4)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
August 1, 2018 INFLUENZA VIRUS VACCINE Administration added drugs cdl p1b (41)
January 1, 2019 BEXAROTENE Restriction added drugs cdl p1a (22)
January 1, 2019 LEVONORGESTREL Restriction removed drugs cdl p2 (10)
April 1, 2019 CERITINIB Restriction changed drugs cdl p1a (36)
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2. 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 January 1, 2019
NDC Labeler Code Contracting Company's Name
00254 PAR PHARMACEUTICAL INC.
10148 COTHERIX, INC.
16781 ONSET DERMATOLOGICS LLC
24689 APNAR PHARMA LP
42192 ACELLA PHARMACEUTICALS, LLC
46017 MYLAN CONSUMER HEALTHCARE, INC.
50228 SCIEGEN PHARMACEUTICALS, INC.
52856 PTC THERAPEUTICS, INC.
61145 REPHARM LLC
69292 AMICI PHARMACEUTICALS LLC
69557 SCILEX PHARMACEUTICALS
70127 GREENWICH BIOSCIENCES INC.
70428 DERMIRA, INC.
70594 XELLIA PHARMACEUTICALS USA, LLC
70677 MCKESSON CORPORATION
70726 ITF PHARMA, INC.
71258 PROGENICS PHARMACEUTICALS, INC.
71336 ALNYLAM PHARMACEUTICALS, INC.
71369 AKARX, INC.
71558 INSMED INCORPORATED
71717 MEGALITH PHARMACEUTICALS INC.
71773 TETRAPHASE PHARMACEUTICALS, INC.
71779 VERASTEM, INC.
71904 AMICUS THERAPEUTICS, INC.
72126 AKCEA THERAPEUTICS, INC.
72205 NOVADOZ PHARMACEUTICALS, LLC
72245 FORTE BIO-PHARMA LLC
72511 AMGEN USA 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 (4, 5, 7–11, 13, 18–20)
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3. Updates to the List of Contracted Sterile Needles

Effective for dates of service on or after January 1, 2019, six products by Arkray USA, Inc and one product by Becton, Dickinson and Company (BD) are added to the List of Contracted Sterile Needles (HCPCS A4215) and are eligible for reimbursement.

Effective for dates of service on or after March 1, 2019, manufacturer item numbers 320119 and 320109 by BD are updated with a new maximum allowable product cost (MAPC).

The Universal Product Number (UPN) on the claim billed must be the exact UPN on the dispensed product's package. Listing of contracted products does not guarantee the product's availability.

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4. Updates to the List of Contracted Wound Care Advanced Dressings

Effective for dates of service on or after February 1, 2019, certain products from manufacturers Ferris Mfg. Corp., Hartmann USA, Inc. and Hydrofera, LLC are added to the List of Contracted Wound Care Advanced Dressings.

Effective for dates of service on or after April 1, 2019, certain products from manufacturers Hartmann USA, Inc. and Hollister are deleted from the List of Contracted Wound Care Advanced Dressings and are no longer reimbursable. The maximum acquisition cost (MAC) for products deleted from the list is no longer guaranteed by the manufacturer.

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5. Enteral Nutrition Product-Specific Criteria Modified for Compleat Products

Effective for dates of service on or after October 22, 2018, the product-specific criteria restricting all Compleat products by Nestlé HealthCare Nutrition in the standard category are modified. To be considered for authorization of Compleat products, the beneficiary must meet the medical criteria for standard products and all of the following product-specific criteria:

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

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. Pharmacy Provider Self-Attestation Mailer Arriving Early January 2019

In the second week of January 2019, fee-for-service Medi-Cal pharmacy providers should receive a mailer. This mailer features important information regarding the upcoming claim volume attestation for providers seeking the higher of two professional dispensing fees as part of the forthcoming reimbursement changes for covered outpatient drugs. The URL to the online attestation portal that goes live mid-January 2019 will be included, as well as a unique login ID and password to access the portal.

Note:

Most chain pharmacies will not receive the mailer because most chain pharmacies are coordinating attestations via a corporate point-of-contact.

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 (Medi-Cal and non-Medi-Cal) annual pharmacy claim volume ($13.20 if fewer than 90,000 claims per year; $10.05 if 90,000 claims or more). Reporting the claim volume is a self-attestation process, which will be submitted electronically and must be done annually.

Note:

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

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

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

For additional information, providers can refer to the Pharmacy Provider Self-Attestation FAQs on the Medi-Cal website or the Pharmacy Reimbursement Project page on the DHCS website. For inquiries not covered in either, providers may call the Telephone Service Center at 1-800-541-5555 and select option 4 then option 2.

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7. Physician-Administered Drugs Update

The Physician-Administered Drugs section of the Pharmacy provider manual is updated. A summary of drugs that are added is shown below.

Added Drug(s)
Effective Date Drug Summary of Changes
January 1, 2019 RISPERIDONE EXTENDED-RELEASE INJECTION Drug added, administration added, restriction added

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

Provider Manual(s) Page(s) Updated
Pharmacy physician (3)
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8. 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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9. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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Note:

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