PharmacyPrescription Rates for Medicare Beneficiaries

Section § 4425

Explanation

This law says that pharmacies taking part in California's Medi-Cal program must charge Medicare patients no more than the Medi-Cal rate for prescription medications, plus some transmission fees. However, this doesn't apply to over-the-counter or mixed prescriptions. The State Department of Health Care Services helps pharmacies by calculating the correct prices and makes sure they comply with these rules. They also inform Medicare patients about these benefits, provide pricing info online, and require signs at pharmacies to remind patients of their rights. If Medicare starts covering more drugs, the state may reevaluate this rule. If a prescription is covered by insurance, this rule does not apply.

(a)CA Business & Professions Code § 4425(a) As a condition for the participation of a pharmacy in the Medi-Cal program pursuant to Chapter 7 (commencing with Section 14000) of Division 9 of the Welfare and Institutions Code, the pharmacy, upon presentation of a valid prescription for the patient and the patient’s Medicare card, shall charge Medicare beneficiaries a price that does not exceed the Medi-Cal reimbursement rate for prescription medicines, and an amount, as set by the State Department of Health Care Services to cover electronic transmission charges. However, Medicare beneficiaries shall not be allowed to use the Medi-Cal reimbursement rate for over-the-counter medications or compounded prescriptions.
(b)CA Business & Professions Code § 4425(b) The State Department of Health Care Services shall provide a mechanism to calculate and transmit the price to the pharmacy, but shall not apply the Medi-Cal drug utilization review process for purposes of this section.
(c)CA Business & Professions Code § 4425(c) The State Department of Health Care Services shall monitor pharmacy participation with the requirements of subdivision (a).
(d)CA Business & Professions Code § 4425(d) The State Department of Health Care Services shall conduct an outreach program to inform Medicare beneficiaries of their right to participate in the program described in subdivision (a), including, but not limited to, the following:
(1)CA Business & Professions Code § 4425(d)(1) Including on its Internet Web site the Medi-Cal reimbursement rate for, at minimum, 200 of the most commonly prescribed medicines and updating this information monthly.
(2)CA Business & Professions Code § 4425(d)(2) Providing a sign to participating pharmacies that the pharmacies shall prominently display at the point of service and at the point of sale, reminding the Medicare beneficiaries to ask that the charge for their prescription be the same amount as the Medi-Cal reimbursement rate and providing the department’s telephone number, e-mail address, and Internet Web site address to access information about the program.
(e)CA Business & Professions Code § 4425(e) If prescription drugs are added to the scope of benefits available under the federal Medicare program, the Senate Office of Research shall report that fact to the appropriate committees of the Legislature. It is the intent of the Legislature to evaluate the need to continue the implementation of this article under those circumstances.
(f)CA Business & Professions Code § 4425(f) This section shall not apply to a prescription that is covered by insurance.
Medi-Cal program pharmacy participation Medicare beneficiaries ...

Section § 4426

Explanation
The State Department of Health Care Services in California is required to study whether the rates paid for prescription drugs and pharmacy services under the Medi-Cal program are fair and sufficient.
The State Department of Health Care Services shall conduct a study of the adequacy of Medi-Cal pharmacy reimbursement rates including the cost of providing prescription drugs and services.
State Department of Health Care Services Medi-Cal pharmacy reimbursement ...