Welcome to the Department of Health Care Services Welcome to Medi-Cal Welcome to the Department of Health Care Services

Part 2 – Pharmacy

106,894 Bytes206,336 Bytes

Medi-Cal Program (00medi-cal)

3,922 Bytes22,016 Bytes

Medi-Cal Provider Manual Contents

9,015 Bytes30,208 Bytes

Manual Organization (0Amanorg)

23,816 Bytes86,016 Bytes

How to Use This Manual (0Bhwtouse)

21,648 Bytes82,944 Bytes

Getting Started: Where to Find the Answers (0C get start)

17,026 Bytes59,392 Bytes

Contents (Part 2 – Medi-Cal Billing and Policy): Pharmacy (2toc pharm)

112,485 Bytes166,400 Bytes

Appeal Form Completion (appeal form)

23,615 Bytes87,040 Bytes

Blood and Blood Derivatives (blood)

15,572 Bytes53,248 Bytes

California Children's Services (CCS) Program (cal child)

5,600 Bytes32,768 Bytes

California Children’s Services (CCS) Program Approved Hospitals (cal child appr)

9,823 Bytes32,256 Bytes

California Children's Services (CCS) Program Billing (cal child bil)

458,832 Bytes524,800 Bytes

California Children's Services (CCS) Program Billing Example: CMS-1500 (cal child bil cms)

9,952 Bytes40,448 Bytes

CCS Program Billing Guidelines (cal child bil guide)

814,019 Bytes898,048 Bytes

California Children's Services (CCS) Program Billing Example: Pharmacy Claim Forms (cal child bil ph)

20,850 Bytes112,128 Bytes

California Children’s Services (CCS) Program County Office Directory (cal child county)

16,877 Bytes55,808 Bytes

California Children's Services (CCS) Program Eligibility (cal child elig)

9,495 Bytes34,304 Bytes

California Children's Services (CCS) Program Medical Therapy Program (cal child med)

36,132 Bytes67,072 Bytes

California Children's Services (CCS) Program Provider Paneling (cal child panel)

16,759 Bytes90,624 Bytes

Form: California Children’s Services (CCS) Program Individual Provider Paneling Application for Physicians and Podiatrists (DHS 4514)

20,274 Bytes102,912 Bytes

Form: California Children’s Services (CCS) Program Individual Provider Paneling Application for Allied Health Care Professionals (DHS 4515 )

12,914 Bytes72,704 Bytes

California Children's Services (CCS) Program Referrals (cal child ref)

27,850 Bytes101,376 Bytes

California Children's Services (CCS) Program Service Authorization Request (SAR) (cal child sar)

67,694 Bytes300,032 Bytes

California Children’s Services (CCS) Program Service Code Groupings (cal child ser)

4,199 Bytes26,624 Bytes

California Children’s Services (CCS) Program Special Care Centers (cal child spec)

10,211 Bytes36,864 Bytes

Child Health and Disability Prevention (CHDP) Program (child)

130,860 Bytes226,816 Bytes

CIF Completion (cif co)

103,149 Bytes162,304 Bytes

CIF Special Billing Instructions (cif sp)

64,864 Bytes100,864 Bytes

CIF Submission and Timeliness Instructions (cif sub)

565,731 Bytes722,432 Bytes

CMS-1500 Completion (cms comp)

196,368 Bytes261,632 Bytes

CMS-1500 Special Billing Instructions (cms spec)

17,983 Bytes77,824 Bytes

CMS-1500 Submission and Timeliness Instructions (cms sub)

13,571 Bytes51,712 Bytes

CMS-1500 Tips for Billing (cms tips)

235,828 Bytes317,952 Bytes

Compound Drug Pharmacy Claim Form (30-4) Completion (compound comp)

1,541,126 Bytes1,728,512 Bytes

Compound Pharmacy Claim Form (30-4) Examples (compound ex)

22,022 Bytes80,384 Bytes

Drug Use Review (DUR) Program (drug)

9,807 Bytes34,816 Bytes

Drugs: Contract Drugs List Introduction (drugs cdl intr)

90,288 Bytes512,512 Bytes

Drugs: Contract Drugs List Part 1 – Prescription Drugs (A through D) (drugs cdl p1a)

99,775 Bytes563,712 Bytes

Drugs: Contract Drugs List Part 1 – Prescription Drugs (E through M) (drugs cdl p1b)

75,456 Bytes400,896 Bytes

Drugs: Contract Drugs List Part 1 – Prescription Drugs (N through R) (drugs cdl p1c)

59,433 Bytes294,912 Bytes

Drugs: Contract Drugs List Part 1 – Prescription Drugs (S through Z) (drugs cdl p1d)

31,804 Bytes154,112 Bytes

Drugs: Contract Drugs List Part 2 – Over-the-Counter Drugs (drugs cdl p2)

14,569 Bytes58,880 Bytes

Drugs: Contract Drugs List Part 3 – Over-the-Counter Cold/Cough Preparations (drugs cdl p3)

40,571 Bytes152,576 Bytes

Drugs: Contract Drugs List Part 4 – Therapeutic Classifications (drugs cdl p4)

54,754 Bytes613,888 Bytes

Drugs: Contract Drugs List Part 5 – Authorized Manufacturer Labeler Codes (drugs cdl p5)

18,628 Bytes78,848 Bytes

Drugs: Contract Drugs List Part 6 – Deleted Drugs (drugs cdl p6)

5,934 Bytes41,472 Bytes

Drugs: Contract Drugs List Part 7 - Preferred TAR-Approved Drug List (drugs cdl p7)

11,375 Bytes44,032 Bytes

Drugs: Contract Drugs List Part 8 – Step Therapy (drugs cdl p8)

18,231 Bytes73,728 Bytes

Drugs: Contract Drugs List Part 10 – MAIC List (drugs cdl pa10)

6,641 Bytes31,232 Bytes

Drugs: MAIC Rate Review (drugs maic rate)

16,012 Bytes77,824 Bytes

Form: California MAIC Rate Review Application (CAMRRA) (MC 3150)

31,280 Bytes108,032 Bytes

Durable Medical Equipment (DME): An Overview (dura)

99,820 Bytes122,368 Bytes

Form: Certificate of Medical Necessity for All Durable Medical Equipment (DME) (Except Wheelchairs and Scooters) (DHS 6181)

7,333 Bytes40,448 Bytes

Form: Certificate of Medical Necessity for Apnea Monitors (MC 4600)

7,182 Bytes41,472 Bytes

Form: Certificate of Medical Necessity for Nebulizers (MC 4601)

12,058 Bytes52,736 Bytes

Form: Certificate of Medical Necessity for Oxygen (MC 4602)

58,659 Bytes240,640 Bytes

Durable Medical Equipment (DME): Bill for DME (dura bil dme)

16,482 Bytes57,856 Bytes

Durable Medical Equipment (DME): Bill for Infusion Equipment (dura bil inf)

51,602 Bytes233,472 Bytes

Durable Medical Equipment (DME): Bill for Oxygen and Respiratory Equipment (dura bil oxy)

53,807 Bytes269,824 Bytes

Durable Medical Equipment (DME): Bill for Therapeutic Anti-Decubitus Mattresses and Bed Products (dura bil thp)

30,040 Bytes119,296 Bytes

Durable Medical Equipment (DME): Bill for Wheelchairs and Wheelchair Accessories (dura bil wheel)

274,925 Bytes352,256 Bytes

Form: Certificate of Medical Necessity for a Manual Wheelchair, Standard or Custom (DHS 6181-A)

282,134 Bytes359,424 Bytes

Form: Certificate of Medical Necessity for a Motorized Wheelchair, Custom or Standard (DHS 6181-B)

249,872 Bytes330,240 Bytes

Form: Certificate of Medical Necessity for a Power Operated Vehicle (POV) aka Scooter, Standard or Bariatric (DHS 6181-C)

91,589 Bytes750,080 Bytes

Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates (dura cd)

10,071 Bytes40,448 Bytes

Durable Medical Equipment (DME): Billing Codes for California Children's Services (CCS) (dura cd ccs)

19,889 Bytes98,816 Bytes

Durable Medical Equipment (DME) Billing Codes: Frequency Limits (dura cd fre)

4,034,713 Bytes4,481,024 Bytes

Durable Medical Equipment (DME): Billing Examples (dura ex)

45,299 Bytes176,640 Bytes

Durable Medical Equipment (DME): Wheelchair and Wheelchair Accessories Guidelines (dura wheel guide)

28,462 Bytes131,584 Bytes

End of Life Option Act Services (eloa)

978,450 Bytes1,127,936 Bytes

End of Life Option Act Services Billing Examples: CMS-1500 (eloa cms)

37,019 Bytes168,448 Bytes

Enteral Nutrition Products (enteral)

13,843 Bytes43,520 Bytes

Forms: Legibility and Completion Standards (forms leg)

9,676 Bytes32,256 Bytes

Forms Reorder Request: Guidelines (forms reo)

162,697 Bytes289,792 Bytes

Forms Reorder Request: Pharmacy (forms reo ph)

30,815 Bytes112,640 Bytes

Genetically Handicapped Persons Program (GHPP) (genetic)

37,195 Bytes142,336 Bytes

Immunizations (immun)

11,572 Bytes37,376 Bytes

Immunizations Code List (immun cd)

30,924 Bytes121,856 Bytes

Incontinence Medical Supplies (incont)

449,806 Bytes521,216 Bytes

Incontinence Medical Supplies Example: CMS-1500 (incont ex)

13,992 Bytes87,040 Bytes

Incontinence Supplies Prescription Form: Completion (incont sup com)

7,770 Bytes53,248 Bytes

Form: Incontinence Supplies Prescription Form

16,988 Bytes67,584 Bytes

Injections: An Overview (inject an over)

35,520 Bytes121,344 Bytes

Injections: Code List (inject cd list)

65,131 Bytes245,248 Bytes

Injections: Drugs A-D Policy (inject drug a-d)

59,136 Bytes232,448 Bytes

Injections: Drugs E-H Policy (inject drug e-h)

41,709 Bytes155,648 Bytes

Injections: Drugs I-M Policy (inject drug i-m)

37,206 Bytes136,704 Bytes

Injections: Drugs N-R Policy (inject drug n-r)

41,696 Bytes156,160 Bytes

Injections: Drugs S-Z Policy (inject drug s-z)

9,650 Bytes38,400 Bytes

Injections: Hydration (inject hydra)

11,442 Bytes44,544 Bytes

Intravenous or Intra-arterial Solutions: Administration Sets (iv sol admin)

14,321 Bytes49,664 Bytes

Intravenous or Intra-arterial Solutions: Special Billing (iv sol spec)

28,088 Bytes110,080 Bytes

Medical Supplies (mc sup)

469,992 Bytes576,000 Bytes

Medical Supplies: Billing Examples (mc sup ex)

8,444 Bytes47,616 Bytes

Medicare Covered Drugs (medicare drugs)

34,385 Bytes142,336 Bytes

Medicare/Medi-Cal Crossover Claims: Pharmacy Services (medi cr ph)

5,229,481 Bytes5,747,200 Bytes

Medicare/Medi-Cal Crossover Claims: Pharmacy Services Billing Examples (medi cr ph ex)

44,868 Bytes280,064 Bytes

Medicare/Medi-Cal Crossover Claims: Pharmacy Services Medi-Cal Pricing Examples (medi cr ph pr)

15,653 Bytes65,536 Bytes

Medicare Non-Covered Services: HCPCS Codes (medi non hcp)

33,168 Bytes132,608 Bytes

Optional Benefits Exclusion (opt ben exc)

32,304 Bytes126,464 Bytes

Orthotic and Prosthtic Appliances and Services (ortho)

8,743 Bytes32,256 Bytes

Form: Physician Certification of Medical Necessity for Therapeutic Diabetic Shoes and Inserts (ortho 1 form)

55,591 Bytes308,736 Bytes

Orthotic and Prosthetic Appliances and Services: Criteria for Authorization and Reimbursement – Orthotics (ortho auth ortho)

41,252 Bytes254,976 Bytes

Orthotic and Prosthetic Appliances and Services: Criteria for Authorization and Reimbursement - Prosthetics (ortho auth pros)

61,410 Bytes509,440 Bytes

Orthotic and Prosthetic Appliances: Billing Codes and Reimbursement Rates – Orthotics (ortho cd1)

45,989 Bytes371,200 Bytes

Orthotic and Prosthetic Appliances: Billing Codes and Reimbursement Rates – Prosthetics (ortho cd2)

15,734 Bytes60,416 Bytes

Orthotics and Prosthetics: Frequency Limits for Orthotics (ortho cd fre1)

13,443 Bytes52,736 Bytes

Orthotics and Prosthetics: Frequency Limits for Prosthetics (ortho cd fre2)

1,285,446 Bytes1,440,768 Bytes

Orthotic and Prosthetic Appliances: Billing Examples (ortho ex)

16,266 Bytes54,784 Bytes

Other Health Coverage (OHC) (oth hlth)

449,788 Bytes528,896 Bytes

Pharmacy Claim Form (30-1) Completion (pcf30-1 comp)

2,582,044 Bytes2,803,200 Bytes

Pharmacy Claim Form (30-1) Examples (pcf30-1 ex)

15,762 Bytes50,176 Bytes

Pharmacy Claim Form (30-1): Special Billing Instructions (pcf30-1 spec)

16,894 Bytes67,072 Bytes

Pharmacy Claim Form (30-1): Submission and Timeliness Instructions (pcf30-1 sub)

14,864 Bytes57,856 Bytes

Pharmacy Claim Form (30-1) Tips (pcf30-1 tips)

13,075 Bytes46,592 Bytes

Physician-Administered Drugs (physician)

21,221 Bytes73,728 Bytes

Presumptive Eligibility for Pregnant Women (presum)

28,145 Bytes98,304 Bytes

Presumptive Eligibility for Pregnant Women: Billing Codes (presum bill)

28,145 Bytes30,720 Bytes

Form: Presumptive Eligibility for Pregnant Women Provider Fact Sheet (presumb prv fact)

10,177 Bytes33,280 Bytes

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (presumfpatfact)

17,006 Bytes77,824 Bytes

Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (MC 264) (Spanish)

17,006 Bytes27,648 Bytes

Form: Explanation of Ineligibility For The Presumptive Eligibility For Pregnant Women Program (presumjnobene)

21,167 Bytes82,432 Bytes

Presumptive Eligibility for Pregnant Women Program Process (presum proc)

17,978 Bytes63,488 Bytes

Presumptive Eligibility for Pregnant Women Provider Enrollment Instructions (presum prov)

10,006 Bytes36,352 Bytes

Presumptive Eligibility for Pregnant Women Provider Enrollment Checklist (presum prov enroll frm)

12,367 Bytes44,032 Bytes

Provider Billing after Beneficiary Reimbursement (Conlan v. Shewry) (prov bil)

26,394 Bytes96,256 Bytes

Reimbursement (reimbursement)

19,041 Bytes105,472 Bytes

Reject Codes for Real-Time Internet Pharmacy (RTIP) (reject cd)

18,930 Bytes107,008 Bytes

Reject Codes for Medi-Cal-Supplied POS Device (reject cd pos)

12,139 Bytes40,448 Bytes

Remittance Advice Details (RAD) (remit adv)

26,127 Bytes167,936 Bytes

Remittance Advice Details (RAD) Examples: Pharmacy (remit ex ph)

10,686 Bytes35,328 Bytes

Remittance Advice Details (RAD): Payments and Claim Status (remit pay)

713,103 Bytes748,032 Bytes

Share of Cost (SOC): 30-1 for Pharmacy (share ph)

12,148 Bytes44,544 Bytes

Sign Language Interpretation (sign)

11,489 Bytes41,984 Bytes

Subacute Care Programs: Adult (subacut adu)

13,070 Bytes46,592 Bytes

Subacute Care Programs: Level of Care for Adults and Children (subacut lev)

14,250 Bytes59,392 Bytes

Form: Information for Authorization/Reauthorization of Subacute Care Services – Adult Subacute Program (DHS 6200 A)

16,111 Bytes63,488 Bytes

Subacute Care Programs: Pediatric (subacut ped)

77,141 Bytes138,240 Bytes

TAR Completion (tar comp)

294,934 Bytes543,232 Bytes

TAR Deferral/Denial Policy (Frank v. Kizer) (tar defer)

29,977 Bytes124,416 Bytes

TAR Field Office Addresses (tar field)

48,903 Bytes97,280 Bytes

TAR Submission: Drug TARs (tar sub drug)

104,194 Bytes151,552 Bytes

TAR Submission: Transmittal Form (tar submis)

10,532 Bytes33,792 Bytes

TAR: Submitting Appeals (tar submit)

32,289 Bytes186,880 Bytes

Taxable and Non-Taxable Items (tax)



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