November 24, 2020
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.
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
Specific billing policy related to this update will be published in a future Medi-Cal Update.