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Changes to Pharmacy and Compound Drug Pharmacy Claim Forms

August 9, 2018

Pharmacy Claim Forms 30-1 and 30-1C, as well as Compound Drug Pharmacy Claim Forms 30-4 and 30-4C, are being updated. Below are the relevant dates pertaining to these updates:

  • Medi-Cal begins accepting the new forms August 27, 2018
  • For original claims, both the new and old claim forms will be accepted through February 28, 2019
  • For original claims, providers are required to submit the new forms beginning March 1, 2019
  • For appeal claims, providers may submit using the old forms through August 31, 2019
  • The old forms will officially no longer be accepted for both original and appeal claims as of September 1, 2019

Providers can order the new forms starting August 24, 2018, by using the Provider Forms Reorder Request and notating “New” next to the quantity. During the transition period, providers can still order the old version of the forms by notating “Old” next to the quantity. Forms can also be ordered by calling the Telephone Service Center at 1-800-541-5555. For instructions on how to complete the Reorder Request, providers may refer to the Forms Reorder Request: Pharmacy section of the Pharmacy provider manual.

Changes to the forms are as follows:


New 30-1 and 30-1C Pharmacy Claim Forms:

  • Prescription Number fields (Boxes 11, 32 and 53) have been expanded to accommodate up to 12 digits
  • A refill number must be entered into the Fill Number field (Boxes 12, 33 and 54)
    • “0” or “00” for original dispensing
    • “1” or “01” to “99” for refill
  • An Emergency Fill (Boxes 16, 37 and 58) indicator can be entered if applicable. If the drug was dispensed in an emergency, use indicator “Y” for “yes” or “N” for “no.”

New 30-4 and 30-4C Compound Drug Pharmacy Claim Forms:

  • Prescription Number field (Box 10) has been expanded to accommodate up to 12 digits
  • A refill number must be entered into the Fill Number field (Box 11)
    • “0” or “00” for original dispensing
    • “1” or “01” to “99” for refill
  • An Emergency Fill (Box 15) indicator can be entered if applicable. If the drug was dispensed in an emergency, use indicator “Y” for “yes” or “N” for “no.”

Note that, due to the addition of two new fields to the forms, claim line 4 has been removed from forms 30-1 and 30-1C. Additionally, ingredient line numbers 24 and 25 were removed from forms 30-4 and 30-4C.

For instructions on how to properly bill using pharmacy claims, refer to the completion and examples sections in the appropriate Part 2 manual. Provider manual updates reflecting these changes will be released in a future Medi-Cal Update.