Fee-for-Service Pharmacy Benefit Reminders and Clarifications

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California Department of Health Care Services

Date: March 12, 2020

Fee-for-Service Pharmacy Benefit Reminders and Clarifications

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.”
  • Social Security Act, Section 1927(d)(5)
  • California W&I Code, Section 14133.37
  • California W&I Code, Section 14185
  • 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).