14132.04. (a) Comprehensive medication management (CMM) services are covered under the Medi-Cal program.
(b) For purposes of this section, the following definitions apply:
(1) "Chronic medical condition" includes, but is not limited to, arthritis, asthma, cardiovascular disease, diabetes, cancer, and depression.
(2) "Comprehensive medication management" means a pharmacist-led, evidence-based, preventive clinical service that aims to ensure optimal use of medications.
(3) "Medication" means
prescription medications, biologics, over-the-counter medications, or nutritional or herbal supplements.
(4) "Medication therapy problems" means the use of unnecessary medication, the need for additional medication, ineffective medication, subtherapeutic dosage, inadequate monitoring, adverse event, medication interaction, excessive dosage, inadequate adherence, availability of more cost-effective medication, or inability of the beneficiary to afford the medication.
(c) CMM services shall be offered to a beneficiary who is referred by a physician and surgeon as having a medical condition that could benefit from the provision of CMM services and who meets one or more of the following criteria:
(1) Is prescribed eight or more prescription drugs or
biologics, collectively by multiple prescribers, to treat or prevent two or more chronic medical conditions.
(2)Is referred by a physician and surgeon as at high risk for medication therapy problems. (3)Is referred by a physician and surgeon as having a medical condition that could benefit from the provision of CMM services, such as providing CMM services to address poor control of a chronic medical condition. (4)
(2) Has been discharged from a hospital, rehabilitation facility, or long-term care health care facility with one or more chronic medical conditions, with a need for a plan to enhance care coordination efforts, including those related to comprehensive transitional care services under the Health Home Program consistent with paragraph (3) of subdivision (b) of Section 14127.2.
(3) Has failed to achieve therapeutic goals and is experiencing adverse effects that are potentially medication related.
(d)CMM services may be offered to a beneficiary who has a medication therapy problem if a physician and surgeon refers the beneficiary to CMM services based on medical criteria not described in subdivision (c). (e)
(d) CMM services provided pursuant to this section shall do all of the following:
(1) Collect and analyze information, addressing both of the following:
(A) Review of the beneficiary's medical record to gather relevant information, including medication lists, laboratory values, diagnostic tests, and a medical problem list.
(B) Comprehensive review of medications and associated health and social history of the beneficiary in consultation with the beneficiary.
(i) For purposes of this subparagraph, "health and
social history" includes, but is not limited to, social determinants of health relevant to medications, such as the ability of the beneficiary to afford the medication, the potential impact of education level, housing, or means of transportation on the beneficiary's ability to use medications as intended, and health literacy level.
(ii) For purposes of this subparagraph, "review of medications" includes, but is not limited to, review of indication, effectiveness, safety, medication adverse effects, medication list reconciliation, adherence, experience, the beneficiary's personal goals of therapy, and how the beneficiary manages their medications at home.
(2) Assess the information and formulate a medication therapy problem list.
(3) Develop a care plan in collaboration with the beneficiary and the beneficiary's health care providers to address the identified medication therapy problems.
(4) Implement the care plan in collaboration with the beneficiary's health care providers, the beneficiary, and the beneficiary's caregivers.
(5) Provide followup and monitoring to optimize the care plan, and identify and resolve medication therapy problems, with the goal of optimizing medication use and improving care. Followup and monitoring shall be coordinated with the physician and surgeon and any other health care providers of the beneficiary.
(e) The department shall establish reimbursement rates and rate billing codes for CMM services provided pursuant to this section by a pharmacist licensed pursuant to Chapter 9 (commencing with Section 4000) of Division 2 of the Business and Professions Code.
(f) This section shall not be construed to expand or restrict the activities that a pharmacist is authorized to perform pursuant to Chapter 9 (commencing with Section 4000) of Division 2 of the Business
and Professions Code. A pharmacist who initiates, adjusts, or discontinues medication in the course of providing CMM services shall do so pursuant to established policies, procedures, or protocols described in Chapter 9 (commencing with Section 4000) of Division 2 of the Business and Professions Code.