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Reimbursement Rate Update for Intrauterine Contraceptive System (Kyleena)

April 18, 2018

An article published in the January 2018 Family PACT Update and Medi-Cal Update titled “2018 CPT-4/HCPCS Annual Update: Policy Updates” informed providers that effective for dates of service on or after February 1, 2018, HCPCS code J7296 (levonorgestrel-releasing intrauterine contraceptive system, [kyleena], 19.5 mg) is a Medi-Cal and Family Planning, Access, Care and Treatment (Family PACT) Program benefit. The current reimbursement rate for code J7296 is $0. The Department of Health Care Services (DHCS) will update the reimbursement rate to $908.97.

Upon implementation of the rate in the system, an Erroneous Payment Correction (EPC) will be issued to address affected claims. No action is required of Medi-Cal and Family PACT providers.

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 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 J7296 is a calendar month, with a maximum allowable of 36 units per device.

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