Medi-Cal Update

Pharmacy | April 2019 | Bulletin 941

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1. Policy Update for Physician Administered Drugs

Effective for dates of service on or after February 1, 2019, the following HCPCS codes are Medi-Cal benefits:

HCPCS Code Description
C9407 Iodine I-131 iobenguane, diagnostic, 1 millicurie
C9408 Iodine I-131 iobenguane, therapeutic, 1 millicurie
J0584 Injection, burosumab-twza, 1 mg
J0599 Injection, C1 esterase inhibitor (human), (Haegarda), 10 units
J2186 Injection, meropenem, vaborbactam, 10 mg/10 mg, (20 mg)
J3245 Injection, tildrakizumab-asmn, 1 mg
J3397 Injection, vestronidase alfa-vjbk, 1 mg
J7177 Injection, human fibrinogen concentrate (fibryga), 1 mg
J9153 Injection, liposomal, 1 mg daunorubicin and 2.27 mg cytarabine
J9229 Injection, inotuzumab ozogamicin, 0.1 mg
Q5107 Injection, bevacizumab-awwb, biosimilar, (mvasi), 10 mg

Policy for these codes is available in the Physician Administered Drugs Policy PDF.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics inject cd list (3, 4, 8–11, 15, 16); inject drug a-d (26–29); inject drug e-h (5, 16, 17, 29, 30); inject drug i-m (22, 23); inject drug s-z (13); non inject (14)

Clinics and Hospitals
General Medicine

chemo drug a-d (14, 15, 26); chemo drug e-o (12); inject cd list (3, 4, 8–11, 15, 16); inject drug a-d (26–29); inject drug e-h (5, 16, 17, 29, 30); inject drug i-m (22, 23); inject drug s-z (13); non inject (14); non ph (12–14)
Obstetrics
Rehabilitation Clinics
inject cd list (3, 4, 8–11, 15, 16); inject drug a-d (26–29); inject drug e-h (5, 16, 17, 29, 30); inject drug i-m (22, 23); inject drug s-z (13); non inject (14); non ph (12–14)
Pharmacy inject cd list (3, 4, 8–11, 15, 16); inject drug a-d (26–29); inject drug e-h (5, 16, 17, 29, 30); inject drug i-m (22, 23); inject drug s-z (13)
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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
Starting with the last checkwrite in May 2019, and continuing over a period of 8 to 10 months, DHCS will begin making retroactive adjustments for impacted claims with dates of service from the policy effective date of April 1, 2017, 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 be rolled 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. Providers can also expect to receive more information in a mailer being sent to the mailing address on file, and in future pharmacy Medi-Cal Updates.

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 web page. 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 a 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. Updated TAR Submission Requirement and Diagnosis Codes for Tocilizumab

Effective for dates of service on or after May 1, 2019, an approved Treatment Authorization Requirement (TAR) is required for reimbursement of HCPCS code J3262 (injection, tocilizumab, 1 mg). The TAR should include clinical documentation that demonstrates the following:

In addition, ICD-10-CM diagnosis codes M05.00 – M06.9 and M08.00 – M08.99 are no longer required for reimbursement. For billing purposes, one (1) unit of the injection equals 1 mg of tocilizumab.

Tocilizumab is for the treatment of recipients 2 years of age and older with the following indications:

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
inject drug s-z (13)
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4. Revisions to 'Injections: Drugs A-D Policy' Manual Section

The Injections: Drugs A-D Policy section of the Medi-Cal provider manual billing information for abobotulinumtoxinA, a botulinum toxin serotype A product, has been revised.

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

Provider Manual(s) Page(s) Updated
Chronic Dialysis Clinics
Clinics and Hospitals
General Medicine
Obstetrics
Pharmacy
Rehabilitation Clinics
inject drug a-d (17, 18)
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5. May 2019 Medi-Cal Provider Seminar

The May Medi-Cal Provider Seminar is scheduled for May 15 – 16, 2019, at the California Center for the Arts in Escondido, California. Providers can access a class schedule for the seminar by visiting the Provider Training web page of the Medi-Cal Learning Portal (MLP) and clicking the seminar date(s) they would like to attend. Providers may RSVP by logging in to the MLP.

Throughout the year, the Department of Health Care Services (DHCS) and the California Medicaid Management Information System (MMIS) Fiscal Intermediary (FI) for Medi-Cal, conduct Medi-Cal training seminars. These seminars, which target both novice and experienced providers and billing staff, cover the following topics:

Providers must register by May 1, 2019, to receive a hard copy of the Medi-Cal provider training workbooks on the date(s) of training. After May 1, 2019, the workbooks will be available only by download on the Medi-Cal Provider Training Workbooks web page of the Medi-Cal website.

Note:

Wi-Fi will not be provided at the seminar. Please plan accordingly.

Providers that require more in-depth claim and billing information have the option to receive one-on-one claims assistance, which is available at all seminars, in the Claims Assistance Room.

Providers may also schedule a custom billing workshop. On the Lookup Regional Representative web page, enter the ZIP code for the area you wish to search and click the “Enter ZIP Code” button. The name of the designated field representative for your area will appear on the map. To contact a regional representative, providers must first contact the Telephone Service Center (TSC) at 1-800-541-5555 and request to be contacted by a representative.

Providers are encouraged to bookmark the Provider Training web page and refer to it often for current seminar information.

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6. June 2019 Medi-Cal Provider Training Webinars

From June 4 through June 27, 2019, Medi-Cal providers may participate in provider training webinars that are:

To register and participate in the live webinars, providers must access training through the Medi-Cal Learning Portal (MLP). Providers will be able to print class materials and ask questions during the training sessions. Recorded webinars will be archived and available for on-demand viewing from the MLP. Detailed instructions about the registration progress for the live webinars and access to recorded webinar classes are available on the Outreach & Education page of the Medi-Cal website.

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8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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