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ACA Federal Upper Limits Implemented

May 2, 2016

On April 15, 2016, the Department of Health Care Services (DHCS) implemented the Patient Protection and Affordable Care Act (ACA) Federal Upper Limit (FUL) rates for certain National Drug Codes (NDCs). For dates of service on or after April 15th, all Centers for Medicare & Medicaid Services (CMS) approved manufacturers of drugs listed in the Contract Drugs List (CDL), with an associated FUL, may be dispensed.

If it is necessary to dispense a product that is reimbursed at a rate below cost, providers may submit a price override Treatment Authorization Request (TAR). It is highly recommended that providers submit medical justification and supporting documentation (such as a purchase invoice) for the TAR field office review. For a current list of products assigned a FUL, please visit the Affordable Care Act Federal Upper Limit (FUL) Reimbursement List Web page on the DHCS website.