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Medi-Cal Update

Pharmacy | January 2021 | Bulletin 984

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1. 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 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.

Effective Date Drug Summary of Changes    Page(s) Updated
October 1, 2020    Naloxegol Oxalate Effective date changed    drugs cdl p1c (3)
January 1, 2021 Insulin Degludec Strength added drugs cdl p1b (64)
January 1, 2021 Insulin Detemir (rDNA Origin) Strength removed,
administration removed
drugs cdl p1b (64)
February 1, 2021    Colchicine Restriction removed drugs cdl p1a (72)
February 1, 2021 Eslicarbazepine Acetate Restriction added drugs cdl p1b (15)
February 1, 2021 Fludarabine Phosphate Restriction removed drugs cdl p1b (29)
February 1, 2021 Glucagon (r-Dna Origin)    Restriction added drugs cdl p1b (45)
February 1, 2021 Ombitasvir/
Restriction changed drugs cdl p1c (24)

2. Clinical Review: Recommendations for the Management of Acute Dental Pain

A new DUR Educational Article titled “Clinical Review: Recommendations for the Management of Acute Dental Pain (PDF format)” is available on the DUR: Educational Articles page of the Medi-Cal website.

3. Physician-Administered Drugs Update

The Physician-Administered Drugs section of the Pharmacy provider manual is updated. A summary of drugs that are changed or deleted is shown below.

Changed Drug(s)
Effective Date Drug Summary of Changes
January 1, 2021    Buprenorphine Extended Release   
Injectable Solution
Note added
January 1, 2021 Naltrexone Extended Release
Injectable Suspension
Note added

Provider Manual(s) Page(s) Updated
Pharmacy physician (1, 2)

4. Updates to The List of Contracted Incontinence Absorbent Products

Effective for dates of service on or after February 1, 2021, Cardinal’s bladder control pad, item number 1100B is reinstated as a contracted product on the List of Contracted Incontinence Absorbent Products.

5. Revised Updates to The List of Enteral Nutrition Products Effective for Dates of Service on or After January 1, 2021

Effective for dates of service on or after January 1, 2021, the following changes apply to the List of Enteral Nutrition Products Effective for Dates of Service on or After January 1, 2021.

  • PediaSure Grow & Gain with and without Fiber, Bottles (4 products), billing codes 70074067532, 70074067534, 70074067536, 70074067538, were added with a MAC price of 0.0061. These product numbers were also removed from the Deletions tab of the List.

  • Enfamil Neuro Pro EnfaCare 22 RTU, case 48 UPC Case Number has been updated to 300875122051

  • PurAmino Jr. 400g, vanilla Medi-Cal Billing Code (NDC-like number) has been updated to 00087512244

  • MCT Procal, unflav, 30x16g sachets, billing code 50600050236, was added to the Specialized product category. Previously, it was only listed as a Metabolic product

  • Product Types revised to ensure alignment with the category criteria in the Provider Manual.

Product-Specific Criteria removed or updated for most products on the List. Please refer to the List of Enteral Nutrition Products Effective for Dates of Service on or After January 1, 2021 for specific product changes.

Note: Listing of a product is not a guarantee of its availability. The product number approved on an authorization must be the same product number dispensed to the beneficiary and claimed for reimbursement by the provider.

The amount reimbursed to providers for enteral nutrition products shall not exceed the published estimated acquisition cost (EAC) plus a 23 percent markup.

Medi-Cal beneficiaries 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, MS 9-17-37
Sacramento, CA  94244-2430

6. 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. In the meantime, pharmacy providers may refer to the updated Pharmacy Provider Self-Attestation FAQs for more information.

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.

7. 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.

8. Provider Manual Revisions

Pages updated due to ongoing provider manual revisions:

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