Medi-Cal Update

Pharmacy | January 2019 | Bulletin 936

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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
October 29, 2018 TALAZOPARIB Drug added, administration added, restrictions added drugs cdl p1d (10)
November 19, 2018 LORLATINIB Drug added, administration added, restrictions added drugs cdl p1b (62)
December 5, 2018 GILTERITINIB Drug added, administration added, restrictions added drugs cdl p1b (29)
December 10, 2018 GLASDEGIB Drug added, administration added, restrictions added drugs cdl p1b (29)
January 1, 2019 NALOXEGOL OXALATE Drug added, administration added, restrictions added drugs cdl p1c (2)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
February 1, 2019 LEDIPASVIR/ SOFOSBUVIR Restriction added drugs cdl p1b (52)
February 1, 2019 SOFOSBUVIR/ VELPATASVIR Restriction added drugs cdl p1d (5)
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2. Alert: New Naxolone Regulations Effective on January 1, 2019

A new DUR Educational Article titled “Alert: New Naxolone Regulations Effective on January 1, 2019” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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3. Corrections to the List of Contracted Tracheostomy Supplies

Effective for dates of service on or after September 1, 2018, the Universal Product Number (UPN) qualifiers for certain products reimbursable under HCPCS code A7526 (tracheostomy tube collar/holder, each) are corrected in the List of Contracted Tracheostomy Supplies.

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4. Disposable Underpad Deleted from the List of Incontinence Absorbent Products

Effective for dates of service on or after March 1, 2019, the disposable underpad by Attends Healthcare Products, Inc. billed under HCPCS codes T4541 (incontinence product, disposable underpad, large, each) with Universal Product Number (UPN) 10086679239535 is deleted from the List of Contracted Incontinence Absorbent Products and is no longer reimbursable. The maximum acquisition cost (MAC) is no longer guaranteed by the manufacturer.

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5. Medi-Cal Pharmacy Provider Self-Attestation Portal Now Open

On January 15, 2019, the online attestation portal opened for fee-for-service Medi-Cal pharmacy providers seeking the higher of two professional dispensing fees as part of the forthcoming reimbursement changes for covered outpatient drugs. During the second week of January 2019, non-chain Medi-Cal pharmacy providers should have received a mailer that includes the URL for the online attestation portal, as well as a unique login ID and password.

Note:

Most chain pharmacies will not receive the mailer because corporate offices are coordinating attestations via a home office 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 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 the 2018 calendar year is 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 will determine 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 (outside of California, call [916] 636-1980), and select the following options:

  1. Option 1 for English or option 2 for Spanish

  2. Option 1 for Provider

  3. Option 4 for Technical Help Desk

  4. Option 2 for Pharmacy

  5. Option 1 for Provider

  6. Option 1 for NPI – enter NPI followed by the pound key (#)

  7. Option 2 for Pharmacy

After following the steps above, the caller will be directed to an agent.

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6. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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