Medi-Cal Update

Pharmacy | December 2019 | Bulletin 958

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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.

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.

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
January 1, 2020 DONEPEZIL HCL Restriction changed drugs cdl p1a (66)
January 1, 2020 FLUTICASONE PROPIONATE Administration added, restriction added drugs cdl p1b (23)
January 1, 2020 RIVASTIGMINE Restriction removed drugs cdl p1c (51)
March 1, 2020 BRINZOLAMIDE AND BRIMONIDINE TARTRATE Restriction removed drugs cdl p1a (26)
March 1, 2020 BROMFENAC Restriction added drugs cdl p1a (27)
March 1, 2020 KETOROLAC TROMETHAMINE Restriction added drugs cdl p1b (49)
March 1, 2020 MOXIFLOXACIN HCL Restriction added drugs cdl p1b (78)
March 1, 2020 NEPAFENAC Restriction added drugs cdl p1c (4)
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2. Improving the Quality of Care: Risks Associated with Use of Gabapentin

A new DUR Educational Article titled “Improving the Quality of Care: Risks Associated with Use of Gabapentin” (PDF format) is available on the DUR: Educational Articles page of the Medi-Cal website.

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3. 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 January 1, 2020
NDC Labeler Code Contracting Company’s Name
21922 ENCUBE ETHICALS
50261 THERAPEUTICSMD
61990 APOLLO PHARMACEUTICALS USA INC.
69800 ADMA BIOLOGICS, INC.
70752 QUAGEN PHARMACUETICALS LLC
71626 MEDSTONE PHARMA LLC
71839 BE PHARMACEUTICALS INC.
72000 NABRIVA THERAPEUTICS US, INC.
72028 HARMONY BIOSCIENCES, LLC
72065 XERIS PHARMACEUTICALS, INC.
72266 FOSUN PHARMA USA
72485 ARMAS PHARMACEUTICALS INC.
72572 CIVICA, INC.
72694 SERVIER PHARMACEUTICALS LLC
 
Terminations, effective January 1, 2020
NDC Labeler Code Contracting Company’s Name
13310 AR SCIENTIFIC, INC.
20482 INSYS THERAPEUTICS, INC.
53329 MEDLINE INDUSTRIES, INC.
66663 PHARMELLE, 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 (6, 7, 10, 11, 14, 16, 18, 20, 21)
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4. Pharmacy Provider Self-Attestation Mailer Arriving Early January 2020

In the second week of January 2020, fee-for-service Medi-Cal Pharmacy providers should receive a mailer. This mailer features important information regarding the upcoming claim volume attestation for providers seeking the higher of two professional dispensing fees as part of the reimbursement for covered outpatient drugs. The URL to the online attestation portal that goes live mid-January 2020 will be included, as well as unique login ID and password to access the portal.

As has been published in previous Medi-Cal Updates, the Department of Health Care Services (DHCS) has implemented 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 repeated 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 calendar year 2019 will be open from January 15, 2020, through February 29, 2020. The web portal will close at 11:59 p.m. on February 29, 2020, and attestations will not be accepted after that time. The attestation for the 2019 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, 2020, through June 30, 2021).

For additional information, providers may refer to the Pharmacy Provider Self-Attestation FAQs page of the Medi-Cal website or the Pharmacy Reimbursement Project page of the DHCS website.

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5. Recommencement of Pharmacy Retroactive Claim Adjustments in February 2020

The Centers for Medicare & Medicaid Services (CMS) published its final rule on covered outpatient drugs (CODs) on February 1, 2016. Under the final rule, each state Medicaid agency was required to adopt a methodology based on actual acquisition cost (AAC) for CODs. As has been published in previous Medi-Cal Updates, pursuant to California's State Plan Amendment 17-002, the Department of Health Care Services (DHCS) implemented a new fee-for-service reimbursement methodology for CODs to comply with the final rule. The associated system changes went into effect on February 23, 2019.

CMS requires that DHCS make retroactive adjustments for claims with dates of service beginning with the policy effective date of April 1, 2017, through the implementation date of February 23, 2019. DHCS processed the first iteration of these adjustments (claims with dates of service in the month of April 2017) in May 2019, and then paused further adjustments. In the fall of 2019, DHCS contacted all Medi-Cal pharmacy providers to notify them of an Alternative Payment Arrangement (APA) for remaining adjustments. Providers could register for this option via an on-line application that was available from October 28, 2019 through and including November 22, 2019. Providers approved for the APA have since been notified by DHCS and will have their remaining adjustments processed separately from the previous adjustment process.

For providers that did not choose the APA, DHCS will resume retroactive adjustments beginning in February 2020, through February 2021, for the remaining impacted claims with dates of service from May 1, 2017, through February 23, 2019.

If you have questions regarding these adjustments, please call the Telephone Service Center at 1-800-541-5555, option 5, followed by option 6.

If providers want additional information regarding the pharmacy retroactive claim adjustments, they may refer to the Frequently Asked Questions (FAQ) page of the Medi-Cal website. Providers may also refer to the Pharmacy Reimbursement Project page of the DHCS website for additional information regarding this project.

DHCS strongly encourages the Medi-Cal pharmacy fee-for-service provider community to closely monitor Medi-Cal Update pharmacy bulletins for additional information regarding any future updates.

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