Medi-Cal Update

Pharmacy | November 2019 | Bulletin 956

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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
August 19, 2019 ENTRECTINIB Drug added, administration added, restrictions added drugs cdl p1b (5)
October 1, 2019 PEXIDARTINIB Drug added, administration added, restrictions added drugs cdl p1c (29)
December 1, 2019 NETARSUDIL/ LATANOPROST Drug added, administration, added, restriction added drugs cdl p1c (4)
December 1, 2019 POLYETHYLENE GLYCOL 3350 AND ELECTROLYTES Drug added, administration added drugs cdl p1c (35)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
January 1, 2019 ABIRATERONE ACETATE Restriction added, strength added drugs cdl p1a (2)
October 1, 2019 EMTRICITABINE/ TENOFOVIR ALAFENAMIDE Restriction added drugs cdl p1b (3)
October 1, 2019 GLECAPREVIR/ PIBRENTASVIR Restriction removed drugs cdl p1b (29)
November 1, 2019 DIAZEPAM Restriction removed drugs cdl p1a (61)
November 1, 2019 OXYBUTYNIN Restriction added drugs cdl p1c (19)
November 1, 2019 TOLTERODINE TARTRATE Administration added, restriction removed drugs cdl p1d (21)
December 1, 2019 METRONIDAZOLE Restrictions added, strength added drugs cdl p1b (72)
December 1, 2019 NETARSUDIL Restriction added drugs cdl p1c (4)
December 1, 2019 RIVAROXABAN Restriction added drugs cdl p1c (51)
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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.

Changes, effective December 1, 2019
NDC Labeler Code Contracting Company’s Name
00642 EXELTIS 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 (5, 21)
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3. In-Line Cartridge Containing Digestive Enzyme Reimbursable as Medical Supply

Effective for dates of service on or after January 1, 2020, HCPCS code B4105 (in-line cartridge containing digestive enzyme(s) for enteral feeding, each) is reimbursable with an approved Treatment Authorization Request (TAR) or Service Authorization Request (SAR) for recipients with cystic fibrosis and exocrine pancreatic insufficiency diagnosis that meet all the conditions listed below. In addition, claims billed using HCPCS code B4105 must include documentation of product cost (an invoice, manufacturer’s catalog page or price list), as an attachment to the claim, for reimbursement.

Documentation must be on the TAR or SAR to support that the recipient meets all of the following conditions, as documented in the recipient’s medical record:

Authorizations for in-line cartridge containing digestive enzyme(s), HCPCS code B4105, are limited to no more than two enzyme cartridges per day for up to three months.

Reauthorization requests for HCPCS code B4105 must include supporting documentation that all of the above conditions are met and the recipient’s BMI has stabilized or improved.

The Medical Supplies Billing Codes, Units and Quantity Limits spreadsheet will be updated at a later date.

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

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
mc sup (9, 11, 12)
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4. Updates to the List of Contracted Diabetic Test Strips and Lancets

Effective for dates of service on or after January 1, 2020, the following products from Arkray USA, Inc. are added to the List of Contracted Diabetic Test Strips and Lancets.

Product Description Billing Code
ASSURE PLATINUM TEST STRIPS box of 30 08317500030
ASSURE LANCE SAFETY LANCET 28 GAUGE box of 30 08317980328
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5. 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
December 1, 2014 BLINATUMOMAB Drug added, administration added, restriction added

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

Provider Manual(s) Page(s) Updated
Pharmacy physician (1)
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6. Updates to Incontinence Creams and Washes

Effective for dates of service on or after January 1, 2020, incontinence creams and washes require authorization and are no longer restricted to recipients under 21 years of age. Products on the List of Contracted Incontinence Creams and Washes are reimbursable with an approved Treatment Authorization Request (TAR) or Service Authorization Request (SAR) for recipients 5 years of age or older. The List of Incontinence Medical Supply Billing Codes is also updated to reflect this change. The Optional Benefits Exclusion section of the appropriate Part 2 manual will be updated in a future Medi-Cal Update.

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

Provider Manual(s) Page(s) Updated
Clinics and Hospitals
Durable Medical Equipment
General Medicine
Long Term Care
Pharmacy
incont (1, 2, 4–7, 9, 12)
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7. Next Pharmacy Provider Self-Attestation Starting January 2020

This article provides information regarding the 2019 calendar year claim volume attestation to fee-for-service (FFS) Medi-Cal pharmacy providers seeking the higher of two professional dispensing fees (PDFs) for fiscal year 2020-21.

As has been published in previous Medi-Cal Updates, the Department of Health Care Services (DHCS) has implemented a new FFS reimbursement methodology for covered outpatient drugs. Part of this new methodology is a two-tiered PDF based on a pharmacy provider’s total (Medi-Cal and non Medi-Cal) annual pharmacy claim volume ($13.20 if less than 90,000 claims per year; $10.05 if 90,000 or more). Reporting claim volume is a self-attestation process, which will be submitted electronically.  (NOTE: DHCS policy is that a claim is equivalent to a dispensed prescription; therefore, the attestation is for total dispensed prescription volume.)

Only FFS Medi-Cal providers dispensing less than 90,000 total prescriptions per calendar year are eligible to receive the higher of the two PDFs, and must complete an attestation in order to receive it. Attestations must be resubmitted for each calendar year.

The attestation period for calendar year 2019 will be open from January 15, 2020 to February 29, 2020 and will determine the PDF component of pharmacy claim reimbursement for claims with dates of service July 1, 2020 through June 30, 2021 (the state’s following fiscal year.) The web portal will close at 11:59 p.m. on February 29, 2020 and attestations will not be accepted after that time.

For additional information regarding the Pharmacy Provider Self Attestation Process, providers should refer to the Frequently Asked Questions.

DHCS received approval in late August 2017 from the Centers for Medicare & Medicaid Services (CMS) for State Plan Amendment 17-002, which modifies Medi-Cal’s payment methodology for covered outpatient drugs. Included as part of those changes is the amount of the PDF, which will change from its current structure to a two-tiered structure depending upon a pharmacy’s total annual claim volume. Providers should refer to the Pharmacy Reimbursement Project web page on the DHCS website for additional information on this project.
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8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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