Medi-Cal Update

Pharmacy | March 2019 | Bulletin 940

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1. Pharmacist Advanced Practice Services are Medi-Cal Benefits

Effective for dates of service on or after April 1, 2019, pharmacist advanced practice services are a covered Medi-Cal benefit. These services include:

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

Provider Manual(s) Page(s) Updated
Pharmacy pharm serv (1–10)
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2. Pharmacy Fee-For-Service Reimbursement Changes Began February 23, 2019

As has been published in previous Medi-Cal Updates, pursuant to California's State Plan Amendment 17-002, as approved by the Centers for Medicare & Medicaid Services (CMS) on August 25, 2017, the Department of Health Care Services (DHCS) implemented a new fee-for-service reimbursement methodology for covered outpatient drugs on February 23, 2019.

Retroactive Claim Adjustments
In the coming months, DHCS will make retroactive adjustments for impacted claims with dates of service on the policy effective date of April 1, 2017, and through the implementation date of February 23, 2019. In a Medi-Cal NewsFlash, DHCS invited Pharmacy Stakeholders to participate in a teleconference conducted on March 26, 2019, presenting how claim adjustments will roll out. A PDF version of the presentation slides are available at the Pharmacy Reimbursement Project page on the DHCS website, under the Latest News heading.

Drug Ingredient Reimbursement Based on Actual Acquisition Cost (AAC)
CMS's National Average Drug Acquisition Cost (NADAC) has been adopted as the basis for AAC for drug ingredient reimbursement. The NADAC is a national drug-pricing benchmark determined by a federal survey representing the national average invoice price for drug products based on invoices from wholesalers and manufacturers submitted by retail community pharmacies. Wholesaler acquisition cost (WAC) plus 0 percent is used as the basis for reimbursement when a NADAC is not available. The NADAC and WAC benchmarks have replaced the average wholesale price (AWP) minus the 17 percent benchmark in the drug ingredient cost reimbursement methodology. The new methodology reimburses the lower of the NADAC, WAC, federal upper limit (FUL), maximum allowable ingredient cost (MAIC) or the pharmacy's usual and customary charge.

Although the MAIC, as authorized by Welfare and Institutions Code (W&I Code), Section 14105.45(b)(4), is part of the “lowest of” formula for drug ingredient reimbursement, DHCS has elected to discontinue all MAICs effective for dates of service on or after April 1, 2017, and to not implement any new MAICs for the time being. Providers will be notified a minimum of 30 days in advance if and when DHCS chooses to implement any new MAICs. Therefore, all products associated with a MAIC prior to April 1, 2017, no longer have an assigned MAIC effective April 1, 2017.

DHCS reminds providers that it is their responsibility to monitor the published NADAC pricing on the CMS Pharmacy Pricing website. Providers may use the NADAC Request for Medicaid Reimbursement Review form to request a rate review. The NADAC Help Desk will research inquiries and evaluate them for potential NADAC updates based upon invoice data collected from the provider initiating the review, additional pharmacy inquiries and other market factors such as compendia price changes.

The CMS NADAC pricing files are updated in the Medi-Cal claims processing system as soon as they become available to the California Medicaid Management Information System (MMIS) Fiscal Intermediary (FI). Providers seeking an adjusted reimbursement may do so via the Claims Inquiry Form (CIF) process.

There may be infrequent instances when an NADAC, WAC or FUL price is not on file for a specific National Drug Code (NDC) that was previously reimbursable. If this situation is encountered, DHCS recommends Medi-Cal pharmacies dispense the prescribed medication available from an alternative manufacturer that is shown to be reimbursable under the new methodology.

Professional Dispensing Fee
The previous professional dispensing fee structure ($7.25 for retail and $8 for Long Term Care pharmacies) has been replaced with a two-tiered professional dispensing fee based upon a pharmacy's total (both Medicaid and non-Medicaid) annual claim volume as follows:

As has been published in previous Medi-Cal Updates, provider attestations for calendar year reporting periods 2016, 2017 and 2018 are now complete. For additional information regarding the self-attestation process, providers can refer to the Pharmacy Provider Self-Attestation FAQs.

Because of the changes in the pharmacy professional dispensing fee structure, there are two specific areas that may require action on the part of impacted providers to ensure proper professional dispensing fee reimbursement:

Providers may refer to the Pharmacy Fee-For-Service Covered Outpatient Drugs FAQs on the Medi-Cal website for additional information. DHCS strongly encourages the Medi-Cal pharmacy fee-for-service provider community to closely monitor upcoming pharmacy Medi-Cal Updates for additional information regarding any future updates.

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3. Drug Safety Communication: Updated Adverse Effects from Fluoroquinolones

A new DUR Educational Article titled “Drug Safety Communication: Updated Adverse Effects from Fluoroquinolones” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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4. 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 April 1, 2019
NDC Labeler Code Contracting Company's Name
10094 AQUESTIVE THERAPEUTICS, INC.
52440 TITAN PHARMACEUTICALS, INC.
61621 ACELRX PHARMACEUTICALS, INC.
69616 CATALYST PHARMACEUTICALS, INC.
69932 BLUE EARTH DIAGNOSTICS
70114 COHERUS BIOSCIENCES, INC.
70403 ARU PHARMA INC.
70505 ANALOG PHARMA, INC.
71225 SLAYBACK PHARMA
71571 KALA PHARMACEUTICALS INC.
71715 PARATEK PHARMACEUTICALS, INC.
71777 LOXO ONCOLOGY, INC.
71858 IBSA PHARMA, INC.
71879 EYEPOINT PHARMACEUTICALS US, INC.
71981 DOMPÉ FARMACEUTICI S.P.A.
72171 NOVIMMUNE S.A.
72187 STEMLINE THERAPEUTICS, INC.
72495 MILLICENT U.S., INC.
72626 ASEGUA THERAPEUTIC LLC
   
Changes, effective April 1, 2019
NDC Labeler Code Contracting Company's Name
00186 ASTRAZENECA PHARMACEUTICALS LP
00310 ASTRAZENECA PHARMACEUTICALS LP
64011 AMAG PHARMACEUTICALS, INC.
   
Terminations, effective April 1, 2019
NDC Labeler Code Contracting Company's Name
24689 APNAR PHARMA LP
49908 ROCHESTER PHARMACEUTICALS
70785 IRONWOOD PHARMACEUTICALS, INC.
71321 BRANDYWINE PHARMACEUTICALS, LLC

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 (3–5, 7, 10, 11, 13, 14, 18–21)
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5. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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