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Label is not found in MDL. of drugs are shown, but there is no label. Wish it said " of NDCs found" (customizable label), followed by the count

Results (if you searched by NDC and your NDC is not shown, those that are shown are generic equivalents)

Code	Description	NDC	Brand Name Generic name	Brand/ Generic/ Repackager	Form & Strength (or Concentration)	Status	Notes

Definition of Status

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Status

Definition

Covered, no restrictions or limits

The HCPCS Code is reimbursable without restrictions (no age, dose, duration, diagnosis, or TAR requirements). Modifiers may be required, or a drug (such as certain anesthetics) may not be separately billable in all situations. Please verify with State Medi-Cal provider manuals regarding exact billing instructions.

Covered, with restrictions and/or limits

The HCPCS Code is reimbursable when billing requirements/limitations are met (ICD-10, age, dose, duration, etc.).

Quantity Limits: While sometimes documentation submitted with the claim is sufficient to override a maximum dose (such as member weight or BSA), other times a TAR is required. Check the MORE INFO notes to see what is required for high doses.

A TAR is always required when other limits or requirements are not met (provider type, ICD-10, Age, dosing frequency/duration). NOTE TO PHC STAFF: Internal manual overrides (EB, EB Notes) are needed when approving a TAR and one or more limits/restrictions are not met.

Medical Benefit, TAR required

The HCPCS/drug requires an approved TAR for reimbursement; approval is guided by PHC drug-specific TAR criteria. These criteria have been developed and approved by the PHC Pharmacy and Therapeutics and Physician Advisory Committees.

Medical Exception, case-by-case

Medical Exceptions (ME) may be made when the submitted TAR includes the documentation necessary for establishing medical necessity; case-by-case review guidelines apply. Some drug classes may have class-specific case-by-case requirements, such as Antineoplastic agents, Antivirals, Antibiotics, and Antifungals. The case-by-case guidelines apply when the PHC Pharmacy and Therapeutics Committee has not yet established drug-specific criteria/requirements.

Self-Administered Drugs

These are drugs/codes which are usually ordered by prescription and dispensed directly to a member by a pharmacy through the pharmacy benefit (Medi-Cal Rx) for the member to use at home. However, when necessary for a medical provider to provide the drug service in a medical setting, a TAR may be submitted for medical necessity review on a case-by-case basis for medical claim reimbursement. There must be a clinical need for the dose(s) to be administered in office in lieu of member filling at the pharmacy. For all drugs in this group, Standard TAR Requirements for Self-Administered Drugs will apply. Some drugs also have drug-specific clinical criteria that that must be met along with the Self-Administered Drug criteria.

Not Covered (per DHCS)

The drug/HCPCS code is not reimbursable based on State Plan, State Plan Amendment(s), Title 22, or All Plan Letters (APLs). This includes (but is not limited to): drugs used to treat erectile dysfunction, infertility, or other sexual dysfunction, and drugs used for cosmetic indications. Because these drugs do not meet the State Medi-Cal definition for medical necessity, TAR exceptions are not allowed. Medical Necessity is defined as: Treatment that is reasonable and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain. Welfare and Institution Code 14059.5(a).

Carved-out to State Medi-Cal Fee-for-Service

These drugs/HCPCS codes are those that are carved out of the PHC Medi-Cal benefit due to being in a carved-out medication class: Antihemophilic blood factor products, certain medications for behavioral health (eg, antipsychotics, some antidepressants), antiviral agents for HIV/AIDS, and those used for the treatment of alcohol and opiate addiction/dependence (buprenorphine, naloxone, disulfiram). In the case of the latter, some medications for the treatment of substance abuse disorder may be a PHC benefit for members enrolled in the PHC Wellness & Recovery benefit (W&R), when provided by a treating W&R facility.

Discontinued NDC, Not Reimbursable

Reimbursable Most NDCs that are more than 18 months past the discontinuation date are dropped from the search tool. Some NDCs may remain in the search tool past the 18th month and if so, will be shown with an Obsolete NDC note. The provider will need to use an alternative (current) NDC for TARs and claims.

Obsolete HCPCS Code

These are codes that have been deactivated by CMS & DHCS, except for retro claims where the date of service falls within the valid date range prior to the code's obsolete date. Notes or the code description will guide users to the current code for the drug.

Code Not Used by PHC

The CMS billing codes shown in this group are not in use by PHC at this time -- but the drug itself is reimbursable using a PHC-preferred code. Read the notes to see what billing code to use instead for PHC claims.

Definition of Restrictions

Icon	Restriction	Definition
	Additional Coverage Notes	Click on the symbol to see coverage explanation/information.
	Additional Coverage Notes	Click on the symbol to see additional coverage explanation/information.
	Age Restriction	Drug is limited to certain age groups, click on the symbol for details.
	Coverage Change News	Upcoming or recent coverage requirements are noted.
	Diagnosis Limit	Click on the symbol to see which indications (ICD-10s) do not require a TAR.
	Discontinued NDC (payable until 18 months past DC)	This NDC is no longer being manufactured. PHC allows reimbursement on discontinued NDCs for dates of service up to 18 months beyond the discontinuation date. Click the symbol for the discontinuation date and last date this NDC can be billed.
	Frequency or Duration Limit	Click on the symbol to see frequency of dose or claim interval limitations.
	Prior Authorization	Click on the symbol to access PHC TAR Requirements (prior authorization criteria). PHC Medical Drug TAR form
	Prior Code or Status Information	Previous billing code or prior status for retroactive requests or other historical purposes.
	Quantity Limit	Click on the symbol to see the maximum units allowed per day.
	Quantity Limit (over time)	Click on the symbol to see the maximum units allowed per stated time period.
	Requirements if QL exceeded	Click on the symbol to see what must be submitted if the dose is over the stated quantity limit.
	User Field 10	Additional space for J3490 billing info if can't fit in UN 1 or 2.

PHC MDL NAVIGATOR™

Search by Drug Name, NDC, HCPCS Code, or Code Description

Selection

Results (if you searched by NDC and your NDC is not shown, those that are shown are generic equivalents)

Definition of Status

Definition of Restrictions

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