Medi-Cal Update

Pharmacy | October 2019 | Bulletin 954

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1. Alert: New Global Guidelines for the Treatment of Asthma

A new DUR Educational Article titled “Alert: New Global Guidelines for the Treatment of Asthma” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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2. Online Applications for Alternative Payment Option Now Being Accepted

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. As was discussed during a statewide pharmacy stakeholder engagement on March 26, 2019, DHCS is operating under a federal mandate and must make retroactive rate adjustments for claims with dates of service between April 1, 2017 (policy effective date), and February 23, 2019 (system implementation date).

Medi-Cal Pharmacy providers experiencing hardship as a result of the retroactive adjustments may now apply for an alternative payment arrangement through the Third Party Liability and Recovery Division (TPLRD), prior to the recommencement of retroactive payment adjustments in February 2020. All fee-for-service Medi-Cal pharmacy providers who submitted pharmacy claims from April 1, 2017, through February 23, 2019, and that have outstanding balances due to DHCS over $1,500, are eligible to submit an application with required documentation (as delineated below) to TPLRD to be considered for an alternative payment arrangement.

Note:

Providers may estimate their total liability outstanding to DHCS by identifying the amount offset from the initial recoupment, and multiplying that amount by 22 (the number of remaining months of claims from the retroactive period).

The online form for alternative payment arrangement applications is now open, from October 28, 2019, through November 22, 2019. The online form will close on November 22, 2019. Applications will not be accepted after that time. Chain pharmacies must complete individual forms specific to each NPI for which they are seeking this arrangement.

All applicants must submit the following information via the online form:

Impacted Medi-Cal Pharmacy providers have been mailed additional information regarding this alternative payment arrangement, sent to the provider mailing address on file in mid-October.

If providers need additional information regarding the alternative payment arrangement process, they may refer to the Frequently Asked Questions (FAQs) page of the Medi-Cal website.

Providers may refer to the >Pharmacy Reimbursement Project web page of the DHCS website for additional information regarding this project.
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