Fee-for-Service Pharmacy Benefit Reminders and Clarifications

March 12, 2020

As the Department of Health Care Services (DHCS) continues to closely monitor the emerging 2019 Novel Coronavirus (COVID-19) situation, DHCS is issuing guidance to Medi-Cal providers in response to questions regarding dispensing policies governing the Medi-Cal fee-for-service (FFS) pharmacy benefit. To that end, DHCS reminds Medi-Cal pharmacy providers of the following existing Medi-Cal FFS pharmacy policies:

  • 100-Day supply – Medi-Cal allows up to a 100-day supply per dispensing of a covered drug. Please note that Medi-Cal has quantity per dispensing utilization control limitations on certain opioid containing medications. These limitations may be overridden through approval of a Treatment Authorization Request (TAR)/Service Authorization Request (SAR). Additionally, state law requires that no prescription for a Schedule III or IV substance may be refilled more than five times and in an amount, for all refills of that prescription taken together, exceeding a 120-day supply. A new prescription for a 100-day supply of a Schedule III or IV controlled substance would need to be generated every 120 days.

  • Six Prescription (6 Rx) Limit: For Medi-Cal FFS recipients impacted by COVID-19, pharmacies are advised to submit a TAR/SAR using the special handling of “Six Prescription Limit” and incorporate the statement “Patient impacted by COVID-19” within the Miscellaneous Information field on the TAR/SAR. If a pharmacy receives a real-time claim denial for frequency limitation, the pharmacy is advised to submit a TAR/SAR using the special handling of “Exceeded Billing Frequency Limit” and incorporate the statement “Patient impacted by COVID-19” within the Miscellaneous Information field on the TAR/SAR.

  • Utilization Management – Utilization limits on quantity, frequency, and duration of medications dispensed to Medi-Cal beneficiaries may be waived by means of an approved TAR/SAR if there is a documented medical necessity to do so. Pharmacies are advised to incorporate the statement “Patient impacted by COVID-19” within the Miscellaneous Information field on the TAR/SAR.

  • Emergency Supply of Medications – Pharmacy providers are required to supply a minimum of 72 hours of prescribed medications in an emergency and may provide the emergency supply without an approved TAR/SAR. Claims for the emergency supply must be submitted for reimbursement through the completion of the Pharmacy Claim Form (30-1) and include the submission of an Emergency Certification Statement as described in the Pharmacy Claim Form (30-1) Completion section of the Pharmacy provider manual. Providers must incorporate the following statement within the general emergency statement: “Patient impacted by COVID-19.”

For more information about program coverage in an emergency, providers may review the statutes mentioned below.

References to this requirement may be found in the following federal and state laws:

  • Social Security Act, Section 1927(d)(5)

  • California W&I Code, Section 14133.37

  • California W&I Code, Section 14185

Emergency services are defined in California Code of Regulations (CCR), Title 22, Section 51056. For the purpose of providing treatment of an emergency medical condition, “emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following conditions:

  • Placing the patient’s health in serious jeopardy

  • Serious impairment to bodily functions

  • Serious dysfunction of any bodily organ or part
  • Early Refills – When necessary, maintenance medications may be filled prior to the date that the medication runs out as long as a minimum of 75 percent of the estimated duration of the supply dispensed has expired. This allowance does not apply to certain medications with quantity/frequency limitations as required by federal and/or state regulations.

  • Prior Authorization (PA) – TARs/SARs are responded to by the end of the next business day after the receipt of the request. Coupled with the requirement for provision of a minimum of a 72-hour supply of medication in emergency situations, the requirement for a TAR/SAR should not result in adherence or compliance issues or cause a break in ongoing therapy. In addition, DHCS can utilize auto adjudication functionalities relative to PA requirements to help streamline and ensure continue access to medications for those impacted by COVID-19.

  • Mail Order – Medi-Cal allows for, and reimburses, mail order pharmacy providers enrolled as a pharmacy provider in the Medi-Cal program.

Going forward, DHCS has informed our pharmacy TAR/SAR staff to use flexibilities if they receive calls and/or inquires relative to prescriptions and COVID-19 concerns. DHCS will also continue to closely monitor the evolving COVID-19 situation and will issue further reminders and guidance as appropriate. In addition, Medi-Cal providers are encouraged to monitor the Medi-Cal website for any pharmacy policy changes and updates.

Questions may be directed to the Telephone Service Center (TSC) at 1-800-541-5555, 8 a.m. to 5 p.m., Monday through Friday, (except holidays).