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Medi-Cal Update

Pharmacy | December 2020 | Bulletin 982

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1. Monthly Six Prescription Limit and Pharmacy Copay are Terminated

On May 13, 2020, in light of the coronavirus disease 2019 (COVID-19) pandemic and pursuant to federally approved State Plan Amendment 20-0024, the Department of Health Care Services (DHCS) temporarily suspended the monthly six prescription (6 Rx) per beneficiary limit outlined in Welfare and Institutions Code (W&I Code), Section 14133.22, until further notice. The 2020 Budget Health Omnibus Trailer Bill – AB 80/SB 102 made that change permanent along with the elimination of the one-dollar pharmacy copay. Therefore, effective January 1, 2021, the monthly 6 Rx per beneficiary limit and the one dollar pharmacy copay will be permanently eliminated.

2. Medi-Cal List of Contract Drugs: COVID-19 Vaccines Pfizer-BioNTech and Moderna Added

The following provider manual sections have been updated with Corona Virus Disease 2019 Vaccines: Drugs: Contract Drugs List Part 1 – Prescription Drugs and Drugs: Contract Drugs List Part 4 – Therapeutic Classifications.

A summary of drug that has been added is shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

Added Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
December 11, 2020, and December 18, 2020 Corona Virus Disease 2019 Vaccine Drug added, administration added, restriction added drugs cdl p1a (73),
drugs cdl p4 (29)

3. Medi-Cal List of Contract Drugs

The following provider manual section(s) have been updated: Drugs: Contract Drugs List Part 1 – Prescription Drugs and Drugs: Contract Drugs List Part 4 – Therapeutic Classifications.

A summary of drugs that have been added or changed is shown below. For additional information, click on the link to the manual section and scroll to the page indicated or use the find feature to search for the particular drug.

Added Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
January 1, 2021 Insulin Aspart (Niacinamide) Drug added, administration added, restriction added drugs cdl p1b (63),
drugs cdl p4 (23)
January 1, 2021 Insulin Degludec Drug added, administration added, restriction added drugs cdl p1b (64),
drugs cdl p4 (23)
January 1, 2021 Insulin Detemir Drug added to part 4 only, Restrictions added and removed drugs cdl p1b (64),
drugs cdl p4 (23)
January 1, 2021 Lasmiditan Succinate Drug added, administration added, restriction added drugs cdl p1b (78),
drugs cdl p4 (14)
January 1, 2021 Liraglutide Drug added, administration added, restriction added drugs cdl p1b (87),
drugs cdl p4 (23)
January 1, 2021 Methylphenidate HCl Drug added, administration added, restriction added drugs cdl p1b (104),
drugs cdl p4 (18)
January 1, 2021 Pancrelipase Drug added, administration added, restriction added drugs cdl p1c (32),
drugs cdl p4 (21)
January 1, 2021 Semaglutide Drug added, administration added, restriction added drugs cdl p1d (3),
drugs cdl p4 (23)

Changed Drug(s)
Effective Date Drug Summary of Changes Page(s) Updated
October 1, 2020 Ulipristal Acetate Restrictions added drugs cdl p1d (44)
November 1, 2020 Naloxegol Oxalate Restriction added drugs cdl p1c (3)
January 1, 2021 Albuterol Sulfate Restriction removed drugs cdl p1a (7)
January 1, 2021 Apraclonidine Restriction removed drugs cdl p1a (22)
January 1, 2021 Diazepam Restriction added, restriction updated drugs cdl p1a (89)
January 1, 2021 Dulaglutide Strengths added drugs cdl p1a (100)
January 1, 2021 Elbasvir/Grazoprevir Note added, note deleted drugs cdl p1b (3)
January 1, 2021 Glecaprevir/Pibrentasvir Restriction updated, note added, note deleted drugs cdl p1b (44)
January 1, 2021 Insulin Aspart Administration added, restriction added drugs cdl p1b (63)
January 1, 2021 Insulin Aspart Protamine Suspension/Insulin Aspart, (rDNA origin) Administration added, restriction added drugs cdl p1b (63)
January 1, 2021 Insulin Lispro (rDNA Origin) Administration updated, restriction updated drugs cdl p1b (65)
January 1, 2021 Ledipasvir/Sofosbuvir Administration added, restriction updated, restriction removed, note added, note deleted drugs cdl p1b (79)
January 1, 2021 Sofosbuvir Restriction updated, administration added, note added, note deleted drugs cdl p1d (7)
January 1, 2021 Sofosbuvir/Velpatasvir Strength added, restriction updated, restriction removed, note added, note deleted drugs cdl p1d (8)
January 1, 2021 Triazolam Restrictions added drugs cdl p1d (40)

4. Authorized Drug Manufacturer Labeler Codes Update

The Drugs: Contract Drugs List Part 5 – Authorized Drug Manufacturer Labeler Codes section has been updated as follows.

Additions, effective January 1, 2021
NDC Labeler Code Contracting Company's Name
71390 Acacia Pharma Ltd
71671 Agile Therapeutics, Inc.
72769 Biocryst Pharmaceuticals, Inc.
73292 NS Pharma, Inc.
73380 Innate Pharma, Inc.
73473 Solaris Pharma Corporation
73594 Pharmacosmos Therapeutics Inc.
79672 Nextgen Pharmaceuticals LLC
Terminations, effective January 1, 2021
NDC Labeler Code Contracting Company's Name
00327 Guardian Labs Div United-Guardian Inc
11788 AiPing Pharmaceutical, Inc.
24090 Akrimax Pharmaceuticals LLC
42238 Vidara Therapeutics Inc.
52747 U.S. Pharmaceutical Corporation (USPCO)
53014 Celltech Pharmaceuticals
58281 Medtronic, Inc.
61364 Biocryst Pharmaceuticals, Inc.
61971 Vista Pharmaceuticals, Inc.

Provider Manual(s) Page(s) Updated
Adult Day Health Care Centers
AIDS Waiver Program
Chronic Dialysis Clinics
Clinics and Hospitals
Expanded Access to Primary Care Program
General Medicine
Heroin Detoxification
Home Health Agencies/Home and Community-Based Services
Hospice Care Program
Multipurpose Senior Services Program
Obstetrics
Pharmacy
Rehabilitation Clinics
drugs cdl p5 (3, 5–7, 10–23)

5. Updates to the List of Contracted Incontinence Absorbent Products

Effective for dates of service on or after January 1, 2021, the List of Contracted Incontinence Absorbent Products is updated. Contracted products have been added, updated and/or deleted for manufacturers Cardinal, Essity, First Quality and Medline.

6. Recommencement of Pharmacy Retroactive Claim Adjustments in February 2021

As has been published in previous Medi-Cal Updates, the Department of Health Care Services (DHCS) temporarily suspended retroactive pharmacy claim adjustments in 2019. DHCS is resuming these retroactive pharmacy claim adjustments beginning in February 2021.

The Centers for Medicare & Medicaid Services (CMS) published its final rule on covered outpatient drugs (CODs) on February 1, 2016. Under the final rule, each state Medicaid agency was required to adopt a methodology based on actual acquisition cost (AAC) for CODs. As was published in previous Medi-Cal Updates, pursuant to California's State Plan Amendment 17-002 approved by The CMS on August 25, 2017, DHCS implemented a new fee-for-service reimbursement methodology for CODs to comply with the final rule. The associated system changes went into effect on February 23, 2019.

CMS required that DHCS make retroactive adjustments for impacted claims with dates of service from the policy effective date of April 1, 2017, through the implementation date of February 23, 2019. DHCS processed the first iteration of these adjustments (claims with dates of service in the month of April 2017) in May 2019, and then paused further adjustments. In the fall of 2019, DHCS contacted all Medi-Cal Pharmacy providers to notify them of an alternative payment arrangement (APA) for remaining adjustments. Providers could register for this option via an online application that was available from October 28, 2019, through November 22, 2019. Providers approved for the APA were notified of the approval by DHCS and will have their remaining adjustments processed differently from the normal recoupment process, and their recoupment will start beginning with the February 11, 2021, warrant date.

For non-APA providers, DHCS will resume retroactive adjustments beginning with the February 19, 2021, warrant date, for the remaining impacted claims with dates of service from May 1, 2017, through February 23, 2019. These adjustments will appear on Remittance Advice Details (RAD) forms beginning February 2021, with RAD code 0812: Covered Outpatient Drug Retroactive Payment Adjustment. The California Medicaid Management Information System (MMIS) Fiscal Intermediary will adjust the affected claims until the full assumption of operations of Medi-Cal Rx, at which time remaining accounts receivables will be transferred to Medi-Cal Rx for continuation of recoupments.

The recoveries are authorized under the provisions of Welfare and Institutions Code (W&I Code), Sections 14176 and 14177, and California Code of Regulations (CCR), Title 22, Section 51458.1(a)(1). In addition, the W&I Code sections authorize DHCS to enter into repayment agreements with providers or offset overpayments against amounts due. If the total warrant amount is not sufficient to offset the recovery, the negative balance will be converted to an accounts receivable transaction and subtracted from future Medi-Cal reimbursements.

Please refer to the updated Frequently Asked Questions on the Medi-Cal Website for additional information.

7. Pharmacy Provider Self-Attestation Process Changes in 2021

Effective April 1, 2021, Medi-Cal pharmacy benefits will be transitioned to and thereafter administered through the fee-for-service delivery system for all Medi-Cal beneficiaries (generally referred to as “Medi-Cal Rx”). The Department of Health Care Services (DHCS) has partnered with Magellan Medicaid Administration, Inc. (Magellan) to provide a wide variety of administrative services and support for Medi-Cal Rx.

Magellan has contracted with Mercer Government Human Services Consulting (Mercer), part of Mercer Health and Benefits, LLC, to administer the annual pharmacy provider self-attestation survey for professional dispensing fee reimbursement. The objective of the next self-attestation survey is to assign professional dispensing fee rates for Medi-Cal enrolled pharmacies beginning July 1, 2021 and ending June 30, 2022.

DHCS, through Mercer, will be initiating the provider self-attestation process in April 2021 for the 2020 calendar year reporting period for those pharmacy providers seeking the higher of two professional dispensing fee rates determined by annual prescription volume. Key changes to the self-attestation process include:

  • The provider self-attestation process for the calendar year 2020 reporting period will begin in April 2021 (in previous years, the survey period was January 15 through the end of February).

  • Mercer, on behalf of Magellan and DHCS, will administer the provider self-attestation survey with options for online submission or an email submission of a Microsoft Excel® formatted template.

  • In addition to the standard online submission, pharmacies will have an additional survey submission option that will allow a bulk submission for multiple locations. The new template will allow a corporate office for chain-affiliated stores under common ownership to submit multiple stores in one self-attestation survey file.

As was done previously, newly approved fee-for-service pharmacy providers that are notified of their enrollment approval after the attestation period closes will receive the higher dispensing fee. However, those same providers will have to attest for subsequent reporting periods in order to continue to be eligible for the higher dispensing fee in subsequent fiscal years.

A virtual stakeholder information session will be held in March 2021 to review the new self-attestation survey process and project timeline.

DHCS reminds the Medi-Cal pharmacy fee-for-service provider community to closely monitor upcoming Medi-Cal pharmacy bulletins for additional information regarding future updates, by signing up via the Medi-Cal Rx Subscription Service.

For updates on Medi-Cal Rx, please visit the Department’s dedicated websites at Medi-Cal Rx and the DHCS Medi-Cal Rx Transition website. In addition, DHCS encourages stakeholders to review the Medi-Cal Rx Frequently Asked Questions (FAQ) document, which continues to be updated as the project advances.

8. Medi-Cal and Family PACT Cover Prescriptions for STI Reinfection Prevention

Medi-Cal and Family Planning, Access, Care and Treatment (Family PACT) programs reimburse medication treatment of a sexually transmitted infection (STI) and reimburse for medication quantities sufficient to prevent reinfection by sex partners of the beneficiary. Expedited Partner Therapy (EPT) is the clinical practice of treating sex partners of patients diagnosed with a STI without first examining the partner. This form of reinfection prevention usually involves patient-delivered partner therapy, an evidence-based practice to reduce reinfection. Since repeat infections are often due to untreated partners, ensuring all recent partners have been treated is a core aspect of clinical management of patients diagnosed with chlamydia, gonorrhea and/or trichomoniasis.

Medi-Cal and Family PACT cover medically necessary services for the treatment of STIs. If a Medi-Cal or Family PACT provider determines preventative treatment of sex partners is necessary to prevent gonorrhea, chlamydia and/or trichomoniasis reinfection, the provider may dispense an appropriate amount of medication directly to the Medi-Cal or Family PACT patient to provide to partner(s). Alternatively, the provider may provide a prescription written in the beneficiary’s (patient’s) name for medications sufficient to treat both the patient and the partner(s).

For Medi-Cal family planning programs, pursuant to family planning encounters, treatment regimens for chlamydia, gonorrhea and/or trichomoniasis may be dispensed in the clinic or by prescription to be dispensed by a pharmacy. For more information about family planning-related services, providers may refer to the Family Planning section of the appropriate Part 2 section of the Medi-Cal Provider Manual or the ben fam rel section of the Family PACT Policies, Procedures and Billing Instructions Manual. For non-family planning encounters, Medi-Cal covers treatment regimens for chlamydia, gonorrhea and/or trichomoniasis by prescription only.

For additional prescribing and clinical guidelines on treating partners of patients diagnosed with STIs, providers may review guidance from the U.S. Centers for Disease Control and Prevention (CDC) and the California Department of Public Health (CDPH).

California legislation allowing EPT

In 2001, Senate Bill 648 (Ortiz, Chapter 835, Statutes of 2000) amended California law to allow EPT for chlamydia. In January 2007, Assembly Bill 2280 (Leno, Chapter 771, Statutes of 2006) amended the law to allow EPT for gonorrhea and other sexually transmitted infections.

The current law, Health and Safety Code Section 120582, allows specified health care providers to prescribe and/or dispense, furnish or otherwise provide antibiotic therapy for sex partners of individuals infected with Chlamydia trachomatis, Neisseria gonorrhoeae, or other STIs as determined by the CDPH, even if the provider has not performed an exam of the partner(s). The law provides an exception to the Medical Practice Act, which states that prescribing, dispensing or furnishing dangerous drugs without a good-faith prior examination and medical indication constitutes unprofessional conduct.

To reduce the spread of STIs, the CDC and the CDPH recommend EPT to treat partners of persons with chlamydia or gonorrhea without waiting for a clinical evaluation.

A prescriber can legally write prescriptions to include the partner(s) in the following ways:

  • The prescriber may write a separate prescription if the patient provides the partner’s name.

  • The prescriber may write a single prescription for both the patient and the partner by adding the partner’s name to the prescription and increasing the quantity appropriately.

  • The prescriber may simply add “partner(s)” to the prescription and increase the quantity appropriately.

The preferred option is a separate prescription for each partner; however, all three options are valid prescriptions and can be filled by a pharmacist.

Medi-Cal and Family PACT reimbursement for STI reinfection prevention

Effective February 1, 2020, Medi-Cal and Family PACT have updated their policy for reimbursement for EPT:

  • For the prevention of reinfection from chlamydia, gonorrhea, and trichomoniasis.

  • Allowable by prescription for any visit type or dispensed in clinic for family planning-related visits only.

  • Reimbursement for client dose and up to five partner doses per dispensing.

  • Prescriptions must be written in the name of the enrolled client to be covered by Medi-Cal.

References for EPT guidelines

CDC References

CDPH References

9. Medi-Cal Lengthens Transition Time to Full Implementation – Go-Live on April 1, 2021

Given the ongoing challenges and constantly evolving health care landscape associated with the unprecedented coronavirus disease 2019 (COVID-19) public health emergency (PHE), the Department of Health Care Services (DHCS), in partnership and collaboration with Magellan Medicaid Administration, Inc. (Magellan), has decided to lengthen the time for the full implementation of the transition to Medi-Cal Rx by three  months. DHCS and Magellan will continue to dedicate their combined efforts and rigorous preparations towards Assumption of Operations (AOO) for Medi-Cal Rx on April 1, 2021. In the interim, all current processes and protocols, both effectuated by DHCS and our Medi-Cal managed care plans (MCPs), respectively, will remain unchanged and in place until Medi-Cal Rx launches.

While neither DHCS nor Magellan takes this decision lightly, we are confident that given the COVID-19 PHE, this decision is in the best interests of our Medi-Cal beneficiaries and providers. Lengthening the time for full implementation will help to ensure a more complete transition, as well as mitigate impacts to beneficiaries in accessing their medication. Moving the launch of Medi-Cal Rx to April 1, 2021, will provide additional and valuable opportunities for Medi-Cal providers, beneficiaries, MCPs, and other interested parties to become better acclimated to, and familiar with new Medi-Cal Rx policies and processes, through additional messaging from DHCS and Magellan, additional targeted stakeholder engagement and outreach efforts and additional provider trainings.

Please note that DHCS will be working to update applicable provider guidance and associated Medi-Cal Rx provider bulletins/Newsflash articles in the coming weeks to reflect the April 1, 2021, go-live date. With the exception of the three-month shift in the go-live date, all other aspects of the transition communicated to our providers via bulletins through the Medi-Cal and Medi-Cal Rx websites remain unchanged.

DHCS appreciates your continued support and collaboration relative to this important project and looks forward to the successful launch and AOO of Medi-Cal Rx on April 1, 2021. If you have any questions about this notification, please feel free to direct them to the Medi-Cal Rx Project Team at RxCarveOut@dhcs.ca.gov.

10. Medi-Cal Rx Electronic Claims Submission

Effective April 1, 2021, Magellan Medicaid Administration, Inc. (Magellan) will provide administrative supports and services for Medi-Cal fee-for-service (FFS) pharmacy benefits, collectively referred to as “Medi-Cal Rx.” Medi-Cal Rx will include all pharmacy benefits billed by pharmacy providers on pharmacy claims, for Medi-Cal beneficiaries in both the Medi-Cal FFS and managed care delivery systems.

Under the existing processes in Medi-Cal, Medi-Cal providers choosing to submit claims electronically to the Medi-Cal FFS Fiscal Intermediary (FI) must complete and submit the DHCS 6153 form, titled Medi-Cal Telecommunications Provider And Biller Application/Agreement. The DHCS 6153 form indicates that Medi-Cal providers will be provided with a unique Medi-Cal Submitter Identification (ID) and password, which is used for claims certification purposes, accuracy and correction of claims or payments and more.

In order to reduce the burden on our existing Medi-Cal pharmacy providers and ease the transition to Medi-Cal Rx, as well as to comply with the Governor’s January 1, 2019 Executive Order N-01-2019, the Department of Health Care Services (DHCS) will use the existing DHCS 6153 forms already on file for Medi-Cal pharmacy providers and billers for Medi-Cal Rx electronic claims submission purposes as of April 1, 2021. For Medi-Cal Rx electronic claims submissions, Medi-Cal pharmacy providers will be provided with unique Medi-Cal Rx credentials, which are different than the Medi-Cal Submitter ID and password used for the existing Medi-Cal FFS FI. Providers should note that use of the unique Medi-Cal Rx credentials constitute acceptance of all of the terms and conditions outlined in the existing DHCS 6153 form.

While DHCS recognizes that the DHCS 6153 form currently only references the current Medi-Cal FFS FI, please also note DHCS is in the process of amending the DHCS 6153 form, or create a new form, to specifically reference Magellan and Medi-Cal Rx, inclusive of all related processes and procedures. DHCS aims to release this revised form via Provider Bulletin no later than May 1, 2021. At that time, the Medi-Cal pharmacy provider/biller will need to return the revised DHCS 6153 (or a new) form, within the specified timeframe, to ensure an up-to-date Medi-Cal Rx inclusive agreement is on file.

Until such time, the provider/biller agrees that using the Medi-Cal Rx credentials when submitting an electronic claim will identify the submitter and shall serve as acceptance to the terms and conditions of DHCS’s form DHCS 6153. The provider/biller further acknowledges the necessity of maintaining the privacy of the Medi-Cal Rx credentials and agrees to bear full responsibility for use or misuse of the Medi-Cal Rx credentials, should privacy not be maintained.

If Medi-Cal pharmacy providers/billers have questions regarding this bulletin, please direct all such communications to MediCalRxEducationOutreach@magellanhealth.com.

11. Updates to the List of Enteral Nutrition Products

Effective for claims with dates of service on and after January 1, 2021, the List of Enteral Nutrition Products eligible for reimbursement through the Medi-Cal fee-for-service pharmacy delivery system is updated. The new spreadsheet, List of Enteral Nutrition Products Effective for Dates of Service on or After January 1, 2021, have newly added products, deleted products (on the Deletion Tab), and updated maximum acquisition cost (MAC) and estimated acquisition cost (EAC) for certain products.

The manufacturers guarantee providers can purchase the listed products at or below the MAC, upon request, for dispensing to Medi-Cal fee-for-service outpatient recipients.

Effective for dates of service on or after April 1, 2021, products on the spreadsheet, List of Enteral Nutrition Products Effective for Dates of Service on or After January 1, 2021, Deletion Tab will no longer be reimbursable, even with an approved Treatment Authorization Request (TAR) or Service Authorization Request (SAR). The MAC for these products is no longer guaranteed.

Note: Listing of a product is not a guarantee of its availability. The National Drug Code (NDC)-like product number approved on an authorization must be the same NDC-like product number dispensed to the recipient and claimed for reimbursement by the provider.

Recipients affected by these changes, should seek new prescriptions from their physician and new authorizations from their pharmacy provider for a comparable product on the List of Enteral Nutrition Products Effective for Dates of Service on or After January 1, 2021. Continuing care does not apply.

Medi-Cal recipients denied enteral nutrition products who believe the denial was in error, may ask for a state hearing by contacting the California Department of Social Services at +1-800-743-8525 or +1-855-795-0634, or by sending a written request to:


California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
enteral (1, 2, 15)

12. Pen Needles Policy Changed

Effective for dates of service on or after January 1, 2021, pen needles are billable by fee-for-service pharmacy providers on a pharmacy claim using the product’s 11-digit National Drug Code (NDC).

Pen needles reimbursable through the Medi-Cal fee-for-service delivery system, with or without prior authorization, are subject to the products on the List of Contracted Pen Needles. The 11-digit product NDC on the package (box) dispensed must be an exact match to the NDC billing code on the product list and the NDC submitted on the claim.

Providers are reminded of the upper billing limit (California Code of Regulations, Title 22, Section 51008.1) when billing for pen needles. The claim amount billed for pen needles should not exceed the amount that is the lesser of the following:

  • The usual charges made to the general public;

  • The net purchase price of the item (including all discounts and rebates), which shall be documented in the provider’s books and records, plus no more than 100 percent markup. Documentation shall include, but not be limited to, evidence of purchase such as invoices or receipts; or

  • The maximum allowable product cost (MAPC) of the item published on the List spreadsheet plus 23 percent dealer markup.

The maximum amount reimbursed to providers is the lesser of the following:

  • The amount billed, or

  • The MAPC plus 23 percent dealer markup.

The manufacturers have guaranteed, upon request, that Medi-Cal fee-for-service pharmacy providers can purchase the products listed in the List of Contracted Pen Needles at or below the maximum acquisition cost (MAC) for administering through the Medi-Cal fee-for-service delivery system. A prior authorization is required for pen needles when the quantity needed exceeds the 100 per 30-day period limitation.

The Medical Supplies Billing Codes, Units and Quantity Limits List was also updated.

Provider Manual(s) Page(s) Updated
Durable Medical Equipment
Pharmacy
mc sup (1, 7–15)

13. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:



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