State of California—Health and Human Services Agency Department of Health Care Services TOBY DOUGLAS EDMUND G. BROWN JR. DIRECTOR GOVERNOR Date: May 15, 2014 CCS Information Notice: 14-07 TO: ALL COUNTY CALIFORNIA CHILDREN SERVICES (CCS) AND GENETICALLY HANDICAPPED PERSONS PROGRAM (GHPP) ADMINISTRATORS, MEDICAL CONSULTANTS, COUNTY MEDICAL STAFF, AND SYSTEMS OF CARE DIVISION (SCD) STAFF SUBJECT: SELECT VITAMIN B PREPARATIONS AND ADDITIONAL DIETARY SUPPLEMENTS CONSIDERED MEDI-CAL NON-BENEFITS The purpose of this information notice is to communicate that beginning August 1, 2014, the following vitamin B preparations, determined by the Medi-Cal Program to be non- benefit, will no longer be reimbursable in the Medi-Cal claims system, even with an approved SAR. NDC Label Name Generic Name 50428711989 CVS BIOTIN 5,000 MCG CAPSULE BIOTIN 11917010715 BIOTIN 5,000 MCG TABLET BIOTIN 00904543360 BIOTIN 300 MCG TABLET BIOTIN 68308032610 FABB TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 51991038490 FOLBIC TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 51991008490 FOLBEE TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 00245019111 FOLGARD RX TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 59528031701 NEPHPLEX RX TABLET VIT B CMPLX NO3/FA/C/BIOT/ZINC 36652067762 ALLBEE C-800 TABLET VITAMIN B COMPLEX/VIT C/VIT E In addition, the following products are designated Medi-Cal non-benefit items (TAR2) and will no longer be payable by its 11-digit NDC code. NDC Label Name Generic Name 00122307535 PABA TABLET AMINOBENZOIC ACID (B VIT) 00417003209 PABA 30 MG TABLET AMINOBENZOIC ACID (B VIT) 45541004235 PABA 30 MG TABLET AMINOBENZOIC ACID (B VIT) Systems of Care Division 1515 K Street, Suite 400, Sacramento, CA 95814, P.O. Box 997413, MS 8100 Sacramento, CA 95899-7413 (916) 327-1400 Internet Address: www.dhcs.ca.gov NDC Label Name Generic Name 59528198801 VITAL-D RX TABLET B CMPLX 4/VIT D3/C/FA/ZINC OX 52083032904 APETIGEN PLUS LIQUID B COMP/FERROUS GLUC/LYSIN/ZNOX 52083032908 APETIGEN PLUS LIQUID B COMP/FERROUS GLUC/LYSIN/ZNOX 52083032916 APETIGEN PLUS LIQUID B COMP/FERROUS GLUC/LYSIN/ZNOX VIRT-CAPS (1 MG FA B COMP W- 76439026010 C) B COMPLEX & C NO.20/FOLIC ACID 51759000202 PRORENAL VITAL MULTIVIT TAB B&C/FERROUS FUM/FA/D3/ZINC OX 51759000201 PRORENAL VITAL MULTIVIT TAB B&C/FERROUS FUM/FA/D3/ZINC OX 10432029301 BIOTIN 10 MG TABLET BIOTIN 48107004908 BIOTIN 300 MCG TABLET BIOTIN 08839502482 BIOTIN 1,000 MCG TABLET BIOTIN 57771000192 CYTO B7 5 MG/ML LIQUID BIOTIN 31604042546 BIOTIN 2,500 MCG SOFTGEL BIOTIN 58487002931 BIOTIN 10 MG TABLET BIOTIN 54391000309 BIOTIN 10 MG CAPSULE BIOTIN 11822489950 RA BIOTIN 2,500 MCG CAPSULE BIOTIN 08839502481 BIOTIN 1,000 MCG TABLET BIOTIN 47469005396 BIOTIN 10,000 MCG TABLET BIOTIN 11845007365 BIOTIN 800 MCG TABLET BIOTIN 11845015615 BIOTIN 5,000 MCG TABLET BIOTIN 11845016325 BIOTIN 5,000 MCG SOFTGEL BIOTIN 40986002044 PV BIOTIN 800 MCG TABLET BIOTIN 37205054472 BIOTIN 5,000 MCG CAPSULE BIOTIN 36800015193 BIOTIN 5 MG CAPSULE BIOTIN 96295011918 BIOTIN 5,000 MCG CAPSULE BIOTIN 11917009900 BIOTIN 1,000 MCG TABLET BIOTIN 50428459961 CVS BIOTIN 1,000 MCG TABLET BIOTIN 00259010828 APPEAREX 2.5 MG TABLET BIOTIN 54629398501 BIOTIN 1,000 MCG TABLET BIOTIN 58487029301 BIOTIN 10 MG TABLET BIOTIN 79854003985 BIOTIN 1,000 MCG TABLET BIOTIN 68016002044 PV BIOTIN 800 MCG TABLET BIOTIN 00259010784 APPEAREX 2.5 MG TABLET BIOTIN 00259011284 APPEAREX 2.5 MG TABLET BIOTIN 00394013142 HARD NAILS 2.5 MG CAPSULE BIOTIN 00182406001 BIOTIN 300 MCG TABLET BIOTIN 60814051060 BIOTIN 800 MCG TABLET BIOTIN 81131011147 SV BIOTIN 5,000 MCG SOFTGEL BIOTIN 81131092882 SV BIOTIN 1,000 MCG SOFTGEL BIOTIN 68220009990 CALAFOL RX TABLET CA CARB/D3/B-12/FA/B6/POLICOS 40985022251 COMPLEX B-50 TABLET CA CARBONATE/VIT B COMP/FA 44183033090 FOLIC ACID 2.5 MG TABLET CYANOCOBALAMIN/FA/PYRIDOXINE NDC Label Name Generic Name HOMOCYSTEINE FORMULA 11845125502 TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 79854003838 B COMPLEX-FOLIC ACID TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 42192034590 FOLASTIN TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 12593004790 FOLBALIN PLUS TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 76439020990 VIRT-VITE TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 13811052701 TL GARD RX TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 00245001760 FOLGARD TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 54629038382 B COMPLEX-FOLIC ACID TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 68308078090 FOLAMIN TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 68308032410 FOLCAPS TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 00525085560 FOLTX TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 00245018311 FOLIC ACID-VIT B6-VIT B12 TAB CYANOCOBALAMIN/FA/PYRIDOXINE 68047073390 MYO VYT TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 51991025201 FOLPLEX 2.2 TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 76439020190 VIRT-VITE FORTE TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 00525085590 FOLTX TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 68308032560 FOLTABS 800 TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 13925012690 CAVAN-X TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 60575091390 VITA-RESPA TABLET CYANOCOBALAMIN/FA/PYRIDOXINE 10542001409 DIALYVITE 3,000 TABLET FA/VIT BCOMP&C/SE/MIN AA/ZN 10542002509 DIALYVITE 800-ULTRA D TABLET FA/VIT BCOMP&C/ZINC/VITAMIN D3 76439021090 VIRT-VITE PLUS TABLET FOLIC ACID/B COMPLEX & C NO.17 00525055590 CEREFOLIN NAC CAPLET LMFOL CA/ACETYL/MB12/ALGAL OIL 51991091190 METAFOLBIC PLUS RF CAPLET LMFOL CA/ACETYL/MB12/ALGAL OIL L-METHYLFOLATE- 18011055590 MECOBALAMIN-NAC LMFOL CA/ACETYL/MB12/ALGAL OIL 42192031190 FOLAST TABLET MECOBALAMIN/L-MEFOLATE/B6 PHOS 68220001890 FOLPACE RX TABLET MGOX/E AC SUCC/B-12/FA/B6 10542001109 DIALYVITE 5000 TABLET MULTIVIT, MINCMB#11/FOLIC ACID 10542000909 DIALYVITE SUPREME D TABLET MULTIVITAMIN, MIN CMB#25/FA/D3 65224059060 SYNAGEX CAPSULE MV, MIN CMB#26/FA/ALA/LUTEIN AMINOBENZOATE POT 500 MG 60267095325 CAP POTASSIUM AMINOBENZOATE 00516005110 POTABA 500 MG CAPSULE POTASSIUM AMINOBENZOATE 00516005125 POTABA 500 MG CAPSULE POTASSIUM AMINOBENZOATE 00516005250 POTABA ENVULE 2 GM POTASSIUM AMINOBENZOATE 00516005401 POTABA 500 MG TABLET POTASSIUM AMINOBENZOATE 00516005410 POTABA 500 MG TABLET POTASSIUM AMINOBENZOATE AMINOBENZOATE POT ENVULE 2 60258084150 GM POTASSIUM AMINOBENZOATE AMINOBENZOATE POT 500 MG 60258084025 CAP POTASSIUM AMINOBENZOATE NDC Label Name Generic Name AMINOBENZOATE POT 500 MG 00115701101 TAB POTASSIUM AMINOBENZOATE 00115703011 AMINOBENZOATE POT PACKET 2G POTASSIUM AMINOBENZOATE 11694011401 PABA TABLET PRT SUPP/YEAST/PABA (B VIT) 53809030501 ARKALIOX 200 MG TABLET SULBUTIAMINE 54629059606 STRESS FORMULA WITH IRON TAB VIT B COMP/C/FA/IRON SULF/VITE 79854020105 STRESS FORMULA WITH IRON TAB VIT B COMP/C/FA/IRON SULF/VITE 11845070405 STRESS-C WITH IRON TABLET VIT B COMP/C/FA/IRON/VIT E 00904026352 STRESS FORMULA WITH IRON TAB VIT B COMP/C/FA/IRON/VIT E 43072000370 VITAMIN B COMPLEX TABLET VIT B COMP/C/FA/IRON/VIT E 10542001210 DIALYVITE WITH ZINC TABLET VIT B CPLX #11/FA/C/BIOT/ZN OX 00179840702 B COMPLEX WITH VITAMIN C TAB VIT B1 MN/B2/B3/B5/B6/B12/C/FA SV B COMPLEX SUBLINGUAL 81131063308 LIQUID VIT B2/NIACIN/B-6/B-12/D-PANTH QUIN B STRONG WITH C & ZINC 58487000272 TB VITAMIN B COMP W-C/FA/ZINC QUIN B STRONG WITH C & ZINC 58487000271 TB VITAMIN B COMP W-C/FA/ZINC 10542001510 DIALYVITE 800-ZINC 15 MG TAB VITAMIN B COMP W-C/FA/ZN CIT 10542005010 DIALYVITE 800-ZINC 50 MG TAB VITAMIN B COMP W-C/FA/ZN CIT 00314001030 B-JECT-100 VIAL VITAMIN B COMPLEX 30727030080 VITAMIN B COMPLEX 100 VIAL VITAMIN B COMPLEX 17022381407 VITAMIN B COMP/B12 VIAL VITAMIN B COMPLEX 62086014630 B-COMPLEX 100 INJECTION VITAMIN B COMPLEX 00402001030 B COMPLEX 100 MG/ML VIAL VITAMIN B COMPLEX 00251543030 LIVERBEX VIAL VITAMIN B COMPLEX/LIVER EXT 00251501010 ASCLEROL VIAL VITAMIN B COMPLEX/LIVER EXT 00525091116 PANTON ELIXIR VITAMIN B COMPLEX/MINERALS 67457014630 B-COMPLEX 100 INJECTION VITAMINS B1,B2,B3,B5,& B6 67157010830 B-COMPLEX 100 INJECTION VITAMINS B1,B2,B3,B5,& B6 79854020170 YEAST TABLET YEAST 00904317570 BREWER'S YEAST 500 MG TABLET YEAST 10135025010 BREWERS YEAST 7.5GR TABLET YEAST 10135025069 BREWERS YEAST 7.5GR TABLET YEAST 54629017202 YEAST TABLET YEAST 10939041911 BREWER'S YEAST 500 MG TABLET YEAST 49348005219 BREWER'S YEAST 500 MG TABLET YEAST 43292022317 BREWER'S YEAST 7.5GR TABLET YEAST 11845073801 BREWER'S YEAST 600 MG TABLET YEAST 11845073802 BREWER'S YEAST 600 MG TABLET YEAST 00084101325 SUPER YEAST W/B-12 TABLET YEAST/CYANOCOBALAMIN 11979072710 TREAS NAT B12/BREW YST TAB YEAST/CYANOCOBALAMIN 17022420004 BREWERS YEAST W/B-12 TAB YEAST/CYANOCOBALAMIN NDC Label Name Generic Name 17022420002 BREWERS YEAST W/B-12 TAB YEAST/CYANOCOBALAMIN 00084104605 SUPER YEAST W/B-12 TABLET YEAST/CYANOCOBALAMIN 00814685722 SELENIUM W/YEAST 25MCG TAB YEAST/SELENIUM 00536685201 SELENIUM W/YEAST 50 MCG TAB YEAST/SELENIUM If you have any questions, please contact: Edan Lum, Pharm D., Pharmaceutical Consultant, 916-327-2616 or 510-286-0708, [email protected] ORIGINAL SIGNED BY DR. ROBERT DIMAND, M.D. Dr. Robert J. Dimand, MD. Chief Medical Officer Systems of Care Division.