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

Medi-Cal Logo
Click to Sign Up for MCSS emails

Reminder: Intrauterine Device Added as Benefit for Medi-Cal and Family PACT

October 9, 2017

An article published in the June 2017 Medi-Cal Update and Family PACT Update titled “New Intrauterine Device Added as Benefit for Medi-Cal and Family PACT” informed providers that, effective for dates of service on or after July 1, 2017, HCPCS code S4989 (contraceptive intrauterine device [levonorgestrel-releasing intrauterine system, 19.5 mg]) is a Medi-Cal and Family Planning, Access, Care and Treatment (Family PACT) Program benefit. It is reimbursable when billed with ICD-10-CM diagnosis codes Z30.430, Z30.431 and Z30.433. The maximum allowable rate for code S4989 is $854.90.

Providers participating as Public Health Service (PHS) entities, and purchasing drugs through PHS 340B program, must not bill more than the actual acquisition cost of the drug, as charged by the manufacturer at a price consistent with the PHS program for covered outpatient drugs. Drugs subject to the PHS program must be billed with modifier UD (Medicaid level of care 13) in accordance with Medi-Cal policy.

Eligible entities, pursuant to Welfare and Institutions Code (W&I Code), Section 14132.01, may also bill a clinic dispensing fee of $12 per unit. The unit for code S4989 is a calendar month, with a maximum allowable of 36 units per device.

Eligible providers will be reimbursed the lesser acquisition cost of either the drug plus the maximum dispensing fee or the Medi-Cal maximum rate on file.