Cal. Code Regs. tit. 22 § 51313.3

Current through Register 2024 Notice Reg. No. 49, December 6, 2024

Section 51313.3 - Limitations on Coverage of Drugs on the Medi-Cal List of Contract Drugs

(a) Drugs on the Medi-Cal List of Contract Drugs shall have the limitations specified in (b) through (g) below.

(b) Code 1 drugs on the List of Contract Drugs marked "*", require prior authorization in accordance with Section 51003 unless used under the conditions specified on the Medi-Cal List of Contract Drugs, and are subject to the prescription documentation requirements of Section 51476(c).

(c) Where drugs are listed by specific dosage forms, their use is limited to such method of administration (e.g., ophthalmic ointments are limited to ophthalmic use) unless prior authorization is obtained.

(d) When a manufactured dosage form or strength is specifically listed, only those dosage forms or strengths listed are allowable for payment, unless prior authorization is obtained. A listed drug, except intravenous solutions, when prepared by the provider in an unlisted dosage form or strength, does not require prior authorization. Long-acting dosage preparations require prior authorization unless specifically listed. Long-acting dosage preparations are drug products physically constructed to give slow-release therapeutic effect.

(e) Common household remedies and the following items are not covered:

(1) Nonlegend drug preparations;

A. Benzoic and Salicylic Acid Ointment (precompounded)

B. Salicylic Acid Cream or Ointment

C. Salicylic Acid Liquid

D. Sodium Chloride Tablets 1Gm

E. Sodium Chloride Tablets 2.5Gm

F. Zinc Oxide Paste

G. Nonlegend Analgesics except for those in part 2 of the Medi-Cal List of Contract Drugs.

(2) Enteral nutritional supplements or replacements, except that these items may be covered, subject to prior authorization, if used as a therapeutic regimen to prevent serious disability or death in patients with medically diagnosed conditions that preclude the full use of regular food.

(3) Vitamin combinations for person over 5 years of age, except for prenatal vitamin-mineral combination products included in part 2 of the Medi-Cal List of Contract Drugs or legend prenatal vitamin-mineral combination products, subject to prior authorization, for use during pregnancy.

(f) Only nonlegend cough and cold drug products which meet the requirements of part 3 of the Medi-Cal List of Contract Drugs are covered. Time-release products are not covered under part 3 of the Medi-Cal List of Contract Drugs.

(g) This section does not apply to items administered or dispensed as part of a physician's, dentist's, or podiatrist's service.

Cal. Code Regs. Tit. 22, § 51313.3

1. New section filed 5-22-91 as an emergency pursuant to Statutes of 1990, chapter 456, section 36, p. 1658-1659; operative 5-22-91 (Register 91, No. 27). A Certificate of Compliance must be transmitted to OAL by 9-19-91 or emergency language will be repealed by operation of law on the following day.
2. New section refiled 9-19-91 as an emergency; operative 9-20-91 (Register 92, No. 4). A Certificate of Compliance must be transmitted to OAL 1-20-92 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 1-23-92 as an emergency; operative 1-17-92 (Register 92, No. 25). A Certificate of Compliance must be transmitted to OAL 5-22-92 or emergency language will be repealed by operation of law on the following day.
4. Certificate of Compliance as to 1-23-92 order transmitted to OAL 5-22-92 and filed 7-6-92 (Register 92, No. 28).
5. Amendment of subsection (e)(3) filed 1-9-95; operative 3-1-95 (Register 95, No. 2).

Note: Authority cited: Sections 14105 and 14124.5, Welfare and Institutions Code. Reference: Sections 14105, 14105.35, 14105.39 and 14132, Welfare and Institutions Code.