Update on Medication Therapy Management Pharmacy Services

June 14, 2024

MTM Pharmacy services may be billed by a Medi-Cal enrolled pharmacy who has an approved Medi-Cal Medication Therapy Management Provider Application (DHCS 6502), as well as a signed a supplemental services agreement for MTM services, with the Department of Health Care Services (DHCS). Providers may refer to the Part 2 Provider Manual for a detailed explanation of MTM benefits.

MTM Pharmacy Services are benefits for eligible Medi-Cal beneficiaries who meet certain qualifying conditions (see Part 2 Provider Manual for a full list). In addition, the Medi-Cal beneficiary must be utilizing a drug (or drugs) for the treatment of a diagnostic condition (see provider manual for a full list). Initially DHCS contracted for MTM services related to:

• HIV/AIDS
• Serious Mental Health conditions (psychotic disorders such as schizophrenia/schizoaffective disorder, bipolar disorder, etc.)
• Cancer
• Hemophilia
• Diabetes

As of August 1, 2022, the following disease categories were added as eligible qualifying conditions for MTM services:

• Autoimmune disorders (e.g. Rheumatoid Arthritis)
• Asthma/Chronic Obstructive Pulmonary Disease (COPD)
• Cystic Fibrosis
• Multiple Sclerosis

As of March 8, 2024, the following disease categories have been added as eligible qualifying conditions for MTM services:

• Alzheimer’s Disease
• Bone Diseases (e.g. Osteoporosis, Osteoarthritis, etc.)
• Cardiovascular Diseases
  
• Dyslipidemia
• End-Stage Renal Disease (ESRD)
• Hepatitis C
  
• Hypertension
  

MTM Pharmacy Services are “carved out” of Managed Care Medi-Cal. Claim submissions must be billed to fee-for-service Medi-Cal on the CMS-1500 health claim form or ASC X12N 837P v.5010 transaction using specific CPT^® codes.

Questions regarding the MTM program should be forwarded to:  MTMquestions@dhcs.ca.gov