Provider Alerts

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To:	Health Plan of San Joaquin (HPSJ) Primary Care and Specialty Physicians
From:	Provider Services Department
Subject:	Increased Reimbursement on Fluoride Varnish Treatment and Expanded Pharmacy Benefit for Fluoride Drops and Tablets
Products:	Medi-Cal

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Effective: November 1, 2015 

• ONLY HPSJ’s Medi-Cal members are affected by the following changes. 
• Fluoride Varnish Treatment
  • Both Primary Care Physicians and Specialists are able to administer the fluoride varnish treatment.
  • CPT Code D1206 to be billed for fluoride varnish treatment.
  • ICD-10 Code is Z41.8.
  • No Prior Authorization is required.
  • Up to three fluoride varnish treatments will be paid, per 12 month period, per HPSJ member.
  • New reimbursement flat rate:
    • $24.00 for each treatment
    • Previously paid at $18.00
  • Age limitation: 0-6 years of age.
• Fluoride Drops and Tablets
  • Prescriptions for fluoride drops and tablets have been expanded.
  • Now, instead of a 30-day supply, a 100-day supply is available for members.
  • Age limitation: 0-16 years of age.

NOTE: With the lack of fluoride in public drinking water for San Joaquin and Stanislaus counties, we encourage either fluoride varnish, or drops, or tablets, for children 0-6 years.

Please direct any questions to our Provider Services Department at (209) 942-6340.