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

Family PACT Claims for Self-Administered Contraceptives Erroneously Denied

January 28, 2019

The Department of Health Care Services (DHCS) identified a claims processing issue causing Family Planning, Access, Care and Treatment (Family PACT) Program pharmacy claims for self-administered hormonal contraceptives to erroneously deny. Claims have denied with National Council for Prescription Drug Programs (NCPDP) reject code M4: Prescription/service reference number/time limit exceeded when the third fill of contraceptive is submitted.

An article published in the August 2018 Family PACT Update titled “Update to Clinic Dispensing Limits for Self-Administered Hormonal Contraceptives” informed providers that up to a 12-month supply of contraceptive vaginal rings, contraceptive patches or oral contraceptives may be dispensed, per prescription fill. A 12-month supply of the same product may be dispensed twice in one year. A Treatment Authorization Request (TAR) is required for the third supply of up to 12 months of the same product requested within a year.

Until the system issue is resolved, pharmacy providers are advised to submit a TAR for the third supply and any subsequent fills of the same product of contraceptive vaginal rings, contraceptive patches or oral contraceptives requested within a year.