22-466m Members Get More Coverage for Medical Supplies under Medi-Cal Rx

Date: 06/15/22

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.

Coverage includes therapeutic continuous glucose monitoring devices and home ­blood pressure monitors

Medi-Cal Rx coverage for medical supplies has changed as follows:

Diabetic supplies

Effective May 1, 2022, the Department of Health Care Services (DHCS) updated restrictions on therapeutic continuous glucose monitoring devices (CGM) to improve access to care. Restrictions are now set at three sensors in a 30-day period with a maximum of nine sensors in a 90-day period. All other restrictions remain in effect. This change has been updated on the “List of Covered Therapeutic Continuous Glucose Monitoring (CGM) Systems” found on the    Medi-Cal Rx website.¹

Therapeutic CGMs require a prior authorization for reimbursement. Specific coverage criteria also apply. For additional coverage information and reimbursement and billing requirements, please refer to the Medi-Cal Rx Provider Manual on the Medi-Cal Rx website.¹

Personal, home blood pressure monitors and cuffs

Effective June 1, 2022, personal home-use blood pressure monitors and blood pressure cuffs for use with personal, home blood pressure monitoring devices will be a covered benefit under Medi-Cal Rx as a pharmacy-billed item.²

Covered products are restricted to the “List of Covered Personal Blood Pressure Monitoring Devices and Blood Pressure Cuffs” found on the Medi-Cal Rx website. Quantity and billing restrictions apply.²

Covered medical supplies

As a reminder, always check the Medi-Cal Rx Scope of Coverage to confirm coverage for medical supplies. The following list includes medical supplies that may or may not be subject to full or partial carve-out.³ Refer to the scope document for details.

• Condoms
• Control solution
• Diabetic test strips
• Diaphragms/cervical caps
• Disposable insulin delivery devices
• Glucometers
• Heparin/saline flush
• Infusion tubing
• Infusion pumps
• Inhaler assistive devices
• Insulin syringes
• Lancets
• Lancing devices
• Ostomy
• Peak flow meter
• Pen needles
• Sterile syringes with needles (non-insulin)
• Therapeutic CGM devices
• Tracheostomy
• Urological
• Wound care

Billing and reimbursement resources

• Medi-Cal Rx website
• List of covered personal blood pressure monitoring devices and blood pressure cuffs

Additional information

Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library.

Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact the Health Net Medi-Cal Provider Services Center within 60 days at 800-675-6110.

_{¹ Information from DHCS Bulletin, Diabetic Supplies – Therapeutic Continuous Glucose Monitoring (CGM) Systems (PDF).} 

_{² Information from DHCS Bulletin, Addition of Blood Pressure Monitors and Blood Pressure Cuffs to Medi-Cal Rx (PDF).}

_{³ List of medical supplies (PDF).}