Pen Needles Policy Changed

November 30, 2020

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 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 (listed below) plus 23 percent dealer markup.

The manufacturers have guaranteed, upon request, that Medi-Cal fee-for-service pharmacy providers can purchase the products listed below 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.

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

The products that will be on this list are as follows:

Product Name NDC MAC/MAPC
TechLITE Pen Needles, (4mm x 32G), 100 count 08317234132 $0.1450
TechLITE Pen Needles, (6mm x 32G); 100 count 08317236132 $0.1450
TechLITE Pen Needles, (5mm x 31G); 100 count 08317235131 $0.1450
TechLITE Pen Needles, (8mm x 31G) 100 count 08317238131 $0.1450
TechLITE Pen Needles, (12mm x 29G) 100 count 08317232129 $0.1450
BD Ultra-Fine Nano 2n Generation 32G x 4 mm (100/box) 08290320550 $0.4626
BD Ultra-Fine Nano Pen Needles 32G x 4 mm (100/box) 08290320122 $0.4626
BD Ultra-Fine III Mini Pen Needle 31G x 5 mm (100/box) 08290320119 $0.4318
BDUltra Fine- Micro Pen Needle 32G x 6 mm (100/box) 08290320749 $0.4318
BD Ultra-Fine III Short Pen Needle 31G x 8 mm (100/box) 08290320109 $0.4267
BD Ultra Fine- Orginal Pen Needles 29G x 12.7 mm (100/box) 08290328203 $0.4494
Pentips Pen Needles (4mm x 32G), 100ct 08470344001 $0.1350
Pentips Pen Needles (5mm x 31G), 100ct 08470345001 $0.1350
Pentips Pen Needles (6mm x 31G), 100ct 08470349001 $0.1350
Pentips Pen Needles (8mm x 31G), 100ct 08470343001 $0.1350
Pentips Pen Needles (12mm x 29G), 100ct 08470342901 $0.1350
Unifine Pentips Pen Needles (4mm x 33G), 100ct 08470356001 $0.1650
Unifine Pentips Pen Needles (4mm x 32G), 100ct 08470354001 $0.1450
Unifine Pentips Pen Needles (5mm x 31G), 100ct 08470355001 $0.1450
Unifine Pentips Pen Needles (5mm x 30G), 100ct 08470355501 $0.1450
Unifine Pentips Pen Needles (6mm x 31G), 100ct 08470359001 $0.1450
Unifine Pentips Pen Needles (6mm x 32G), 100ct 08470359501 $0.1450
Unifine Pentips Pen Needles (8mm x 31G), 100ct 08470353001 $0.1450
Unifine Pentips Pen Needles (12mm x 29G), 100ct 08470352901 $0.1450
Unifine Pentips Plus Pen Needles (4mm x 33G), 100ct 08470386001 $0.1650
Unifine Pentips Plus Pen Needles (4mm x 32G), 100ct 08470384001 $0.1450
Unifine Pentips Plus Pen Needles (5mm x 31G), 100ct 08470385001 $0.1450
Unifine Pentips Plus Pen Needles (5mm x 30G), 100ct 08470385501 $0.1450
Unifine Pentips Plus Pen Needles (6mm x 31G), 100ct 08470389001 $0.1450
Unifine Pentips Plus Pen Needles (8mm x 31G), 100ct 08470383001 $0.1450
Unifine Pentips Plus Pen Needles (12mm x 29G), 100ct 08470382901 $0.1450
TRUEPlus 5 Bevel Pen Needle 29G x 12.7mm 1/2" 100/pkg 56151211001 $0.2500
TRUEPlus 5 Bevel Pen Needle 31G x 5mm 3/16" 100/pkg 56151211101 $0.2500
TRUEplus 5 Bevel Pen Needles 31G x 6mm 1/4" 100/pkg 56151211201 $0.2500
TRUEplus 5 Bevel Pen Needles 31G x 8mm 5/16" 100/pkg 56151211301 $0.2500
TRUEplus 5 Bevel Pen Needles 32G x 4mm 5/32" 100/pkg 56151211401 $0.2500
UltiGuard Safe Pack 32G x 4mm Micro 100ct 08222095435 $0.2600
UltiGuard Safe Pack 31G x 5mm Mini 100ct 08222095534 $0.2400
UltiGuard Safe Pack 31G x 6mm Mini 100ct 08222095633 $0.2400
UltiGuard Safe Pack 32G x 6mm Mini 100ct 08222095626 $0.2400
UltiGuard Safe Pack 31G x 8mm Short 100ct 08222095831 $0.2400
UltiGuard Safe Pack 29G x 12.7mm Original 100ct 08222095121 $0.2400
UltiCare 32G x 4mm Micro 100ct 08222710031 $0.1900
UltiCare 31G x 5mm Mini 100ct 08222710130 $0.1700
UltiCare 31G x 6mm Mini 100ct 08222710048 $0.1700
UltiCare 32G x 6mm Mini 100ct 08222710147 $0.1700
UltiCare 31G x 8mm Short 100ct 08222710055 $0.1700
UltiCare 29G x 12.7mm Original 100ct 08222710062 $0.1700