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Bill Fee-for-Service Medi-Cal for Dolutegravir/Lamivudine

June 10, 2019

In April 2019, the US Food and Drug Administration (FDA) approved Dolutegravir/Lamivudine (Dovato) as the first complete two-drug regimen for Human Immunodeficiency Virus-1 (HIV-1), indicated for infected patients who have never received antiretroviral treatments.

Dolutegravir/lamivudine is a Medi-Cal pharmacy benefit and is undergoing the carve out process. Due to system constrains, this process might take several weeks. In the meantime, dolutegravir/lamivudine claims should be submitted to Medi-Cal fee-for-service using the procedure below:

  • The medication should be dispensed, and a claim for dolutegravir/lamivudine submitted to Medi-Cal fee-for-service to receive a denial
  • A denial is needed to create a transaction record for the date of service (date medication is dispensed)
  • Once the claims processing system is updated, the pharmacy provider should resubmit the denied claim reflecting the appropriate date of service

The pharmacy will not be reimbursed prior to dispensing the drug to the recipient; however, by following the steps above, the reimbursement will be generated once system implementation is complete. The beneficiaries must not be charged for their prescriptions.