Cov Nqi thiab Kev Txiav Txim Siab ntawm Medi-Cal Tshuaj
Medi-Cal them cov txiaj ntsig ntawm kev muag tshuaj uas suav nrog cov tshuaj (lus dab neeg thiab cov tshuaj uas yuav tsis tas yuav muaj ntawv yuav tshuaj (OTC)), cov khoom siv kho mob siv pov tseg rau cov neeg mob sab nraud, thiab cov mis tshuaj rau cov tswv cuab los ntawm qhov kev pab cuam Medi-Cal Rx. Cov nyiaj them rov qab rau cov txiaj ntsig ntawm cov tshuaj uas them nyob rau hauv qhov kev pab cuam Medi-Cal Rx yuav suav nrog tus nqi khoom xyaw, tus nqi faib tshuaj, thiab tus nqi tswj hwm thiab yog tshwj xeeb rau qhov kev thov thiab tus tswv cuab txoj cai. Tsis tas li ntawd xwb, Medi-Cal them rau cov tshuaj uas kws kho mob muab (PADs), cov khoom siv kho mob, thiab cov khoom siv rau kev tswj tsis pub tso zis uas raug them rau ntawm daim ntawv thov kho mob siv tus lej Healthcare Common Procedure Coding System (HCPCS). Tus nqi rau cov txiaj ntsig ntawm tsev muag tshuaj uas raug them rau ntawm daim ntawv thov kho mob yog raws li tus nqi ib tus zuj zus thiab qhov kev thov tag nrho yuav suav nrog feem pua ntawm tus neeg muab tshuaj.
Siv tau rau hnub ua haujlwm rau lossis tom qab Lub Plaub Hlis 1, 2017, kev them rov qab rau cov tshuaj kho mob sab nraud uas them los ntawm Medi-Cal program1 yog qhov qis tshaj plaws ntawm ib qho ntawm cov hauv qab no:
- Tus Nqi Tau Txais Tiag Tiag (AAC) ntxiv rau tus nqi faib tshuaj tshaj lij. AAC yog sib npaug rau qhov qis tshaj plaws ntawm cov hauv qab no:
- Tus Nqi Yuav Tshuaj Hauv Tebchaws (NADAC), lossis thaum tsis muaj NADAC, tus nqi yuav tshuaj lag luam wholesale (WAC),
- Tus nqi khoom xyaw siab tshaj plaws uas tso cai (MAIC),
- Tsoom Fwv Teb Chaws Qib Siab (FUL),
- Tus nqi ib txwm thiab tus nqi ib txwm ntawm lub tsev muag tshuaj.
Lus Cim: Tus nqi khoom ntxiv vim yog lub ntim tshwj xeeb yuav tsis tau them rov qab (piv txwv li, ib qho siv, ib qho koob tshuaj hloov kho lossis ib qho koob tshuaj).
Cov Tshuaj Kho Mob Uas Medi-Cal Rx Them
Cov tshuaj Medi-Cal Rx thiab cov tshuaj OTC raug them rov qab rau ib qho nqi ntawm cov tshuaj uas koj yuav tsum muab ntxiv rau tus lej ntawm cov tshuaj ntxiv rau tus nqi muab tshuaj rau ib qho kev thov.
- Piv txwv li: (Amoxicillin 500mg ntawm $1.00 ib lub tshuaj ntsiav) zaug 30 lub tshuaj ntsiav sib npaug $30.00 ntxiv rau tus nqi faib tshuaj
Cov khoom siv kho mob siv pov tseg rau cov neeg mob sab nraud thiab cov mis tshuaj uas muab rau hauv plab tau txais nyiaj rov qab rau txhua qhov khoom siv lossis cov mis tshuaj (txhua, milliliter, lossis gram) muab ntxiv rau tus lej ntawm cov khoom ntxiv rau 23 feem pua.
- Piv txwv li: (Koob tshuaj cwj mem $1.00 rau ib koob) xee 30 koob sib npaug $30.00 ntxiv rau 23 feem pua ntxiv ($6.90)
- Tus nqi them rov qab rau cov chaw muab tshuaj rau cov mis nyuj noj yog tus nqi kwv yees (EAC) rau ib chav uas teev nyob rau hauv daim ntawv cog lus, ntxiv rau 23 feem pua ntawm kev nce qib. Rau feem ntau cov khoom siv kho mob sab nraud, Assembly Bill 97 (2011)2 tseem cuam tshuam rau cov lus thov kev noj haus hauv plab; qhov twg 10 feem pua kev txo qis siv rau txhua qhov kev thov them, txo cov nyiaj them rov qab rau cov kws muag tshuaj.
Thov saib phau ntawv qhia txog kev muab kev pab kho mob Medi-Cal Rx siv cov kev sib txuas hauv qab no kom paub cov ntaub ntawv tshwj xeeb txog kev them rov qab:
| Kev Pab Cuam Muag Tshuaj Medi-Cal Rx Pawg | Cov Ntaub Ntawv Txog Tus Nqi Tshuaj Rau Lub Yim Hli 2026 |
|---|---|
| Tus nqi ntawm cov tshuaj muaj lus dab neeg thiab cov tshuaj tsis muaj lus dab neeg | Tshooj 4.6.1 thiab 4.6.3 Phau Ntawv Qhia Txog Kev Muab Tshuaj Rx Rau Medi-Cal |
| Tus nqi them rau kev faib khoom tshaj lij | Tshooj 4.6.2 Phau Ntawv Qhia Txog Kev Muab Tshuaj Rx Rau Medi-Cal |
| Cov Tshuaj Sib Xyaws | Tshooj 4.6.7 Phau Ntawv Qhia Txog Kev Muab Tshuaj Rx Rau Medi-Cal |
| Ntshav Factor | Tshooj 4.6.16 Phau Ntawv Qhia Txog Kev Muab Tshuaj Rx Rau Medi-Cal |
| 340B cov ntaub ntawv thov nyiaj pab los ntawm tsev muag tshuaj | Tshooj 4.6.5 Phau Ntawv Qhia Txog Kev Muab Tshuaj Rx Rau Medi-Cal |
| Tus nqi txhaj tshuaj tiv thaiv kab mob | Tshooj 4.6.18 Phau Ntawv Qhia Txog Kev Muab Tshuaj Rx Rau Medi-Cal |
| Kev Pab Cuam Tiv Thaiv Kab Mob Rau Menyuam Yaus | Tshooj 15.9.1 Phau Ntawv Qhia Txog Kev Muab Tshuaj Rx Rau Medi-Cal |
Tus Nqi Muab Tshuaj Rau Kws Kho MobMedi-Cal Rx
Medi-Cal Rx siv ob theem nqi them rau kev muab tshuaj raws li qhov nyiaj thov txhua xyoo ntawm lub tsev muag tshuaj (ob qho tib si Medicaid thiab tsis yog Medicaid) raws li hauv qab no:
- Tsawg dua 90,000 qhov kev thov nyiaj txhua xyoo = $13.20
- 90,000 lossis ntau dua cov kev thov nyiaj txhua xyoo = $10.05
Tus nqi them rau kev muab tshuaj raug ntxiv rau txhua qhov kev thov ua ib qho nyiaj rov qab rau tus neeg muab tshuaj.
Cov Cuab Yeej Tshawb Nrhiav Tshuaj Medi-Cal Rx
Cov Cuab Yeej Tshawb Nrhiav Tshuaj yog ib qho cuab yeej ntawm lub vev xaib Medi-Cal Rx thiab tso cai rau txhua tus neeg tshawb nrhiav cov tshuaj National Drug Code (NDC) lossis lub npe tshuaj hauv qhov kev pab cuam Medi-Cal Rx. Cov cuab yeej yuav raug txhim kho kom pom cov nyiaj rov qab rau ib chav thiab yuav txuas ntxiv tso cai rau cov neeg siv tshawb nrhiav cov tshuaj uas them, txheeb xyuas cov tshuaj twg xav tau kev tso cai ua ntej, txheeb xyuas seb cov tshuaj puas muaj kev txwv Code 1, seb cov tshuaj puas yog generic lossis hom tshuaj, thiab cov National Drug Codes (NDCs) tshwj xeeb. Cov ntaub ntawv hauv qab no tau teev nyob rau hauv Drug Look Up Tool:
- Lub Npe ntawm Daim Ntawv Qhia (Qhov no yuav yog lub npe lag luam lossis lub npe dav dav)
- NDC (NDC tshwj xeeb rau hom tshuaj thiab cov tshuaj generic)
- Hom Tshuaj (Hom Tshuaj lossis Hom Tshuaj General)
- Kev Tso Cai Ua Ntej (qhia seb cov tshuaj puas xav tau kev tso cai ua ntej thiab kuj muaj qhov txuas mus rau "Cov Kev Xaiv Medi-Cal rau PA Submission Guide".)
- Txoj Cai 1 (Qhia seb cov tshuaj puas muaj Txoj Cai 1 (yuav tsum tau ua raws li cov kev cai tshwj xeeb rau kev kuaj mob lossis tus mob) thiab muab qhov txuas mus rau Daim Ntawv Teev Tshuaj Cog Lus (CDL) qhov twg cov neeg siv tuaj yeem saib qhov kev txwv tshwj xeeb ntawm Txoj Cai 1.)
- (Yuav Los Sai Sai) Tus nqi ib chav (Qhov no yog tus nqi ib chav ntawm cov tshuaj. Tus nqi no tsis suav nrog tus nqi faib khoom lossis tus nqi ntxiv thiab yog raws li cov ntaub ntawv nqi tshiab tshaj plaws ntawm First Data Bank. Lub Tuam Txhab Ntaub Ntawv Thawj Zaug yog qhov chaw khaws ntaub ntawv tshuaj ntawm Medi-Cal Rx program.)
Cov Khoom Siv Kho Mob thiab Cov Mis Uas Medi-Cal Them
Qhov Kev Pab Cuam Medi-Cal Rx them rau cov khoom siv kho mob sab nraud thiab cov mis tshuaj, yog tias teev nyob rau hauv daim ntawv teev npe uas tau them lossis tau cog lus. Cov nyiaj them rov qab rau cov txiaj ntsig no sib txawv raws li tus nqi them lossis daim ntawv cog lus rau ib chav, gram, lossis milliliter. Cov kws muag tshuaj tau txais nyiaj rov qab nrog 23 feem pua ntawm txhua qhov kev thov. Cov kev sib txuas hauv qab no ntawm lub vev xaib Medi-Cal Rx muab cov npe nrog cov ntaub ntawv nqi rau cov txiaj ntsig no:
| Cov Nyiaj Pab Rau Kev Muag Tshuaj | Resource |
|---|---|
| Cov Npe Tshuaj thiab Cov Khoom Uas Tau Cog Lus | Daim Ntawv Teev Cov Tshuaj Siv Los Ntawm Daim Ntawv Cog Lus Medi-Cal Rx (CDL) |
| Daim Ntawv Teev Cov Khoom Noj Khoom Haus Uas Tau Cog Lus | Daim Ntawv Teev Npe Tshuaj Enteral Uas Tau Cog Lus Los Ntawm Medi-Cal Rx |
| Daim Ntawv Teev Cov Khoom Siv Kho Mob Medi-Cal Rx Uas Them Nqi | Cov Lus Piav Qhia Txog Cov Khoom Siv Kho Mob thiab Cov Ntaub Ntawv Them Nqi |
Cov Nyiaj Pab Them Rov Qab Rau Medi-Cal Hauv Kev Thov Kho Mob Siv Tus lej HCPCS
Medi-Cal them rau cov tshuaj uas kws kho mob muab (PADs), cov khoom siv kho mob pov tseg, thiab cov khoom siv kho mob uas tsis tuaj yeem tso zis tau raws li daim ntawv thov kho mob siv tus lej Healthcare Common Procedure Coding System (HCPCS). Tus nqi rau cov txiaj ntsig ntawm tsev muag tshuaj uas raug them rau ntawm daim ntawv thov kho mob yog raws li tus nqi ib tus zuj zus thiab qhov kev thov tag nrho yuav suav nrog feem pua ntawm tus neeg muab kev pabcuam tsev muag tshuaj. Thov saib cov peev txheej hauv qab no rau cov nqi tshwj xeeb ntawm HCPCS rau cov txiaj ntsig ntawm lub tsev muag tshuaj.
| Cov Nyiaj Pab Rau Kev Muag Tshuaj | Resource |
|---|---|
| Cov txheej txheem Medi-Cal suav nrog PADs | Cov Nqi Medi-Cal raws li Cov Cai Txheej Txheem |
| Phau Ntawv Qhia Txog Kev Muab Kev Pabcuam PADs | Txoj kev them rov qab rau cov tshuaj uas kws kho mob muab (PAD) |
| Cov Nqi Them Rov Qab ntawm PAD | Medi-Cal Cov Nqi Them Rov Qab Siab Tshaj Plaws rau PAD |
| Cov Cai Tswjfwm Kev Pabcuam Kws Muag Tshuaj thiab Cov Ntaub Ntawv Txog Kev Them Nqi | Cov kws kho mob |
| Cov Cai, Kev Them Nqi, thiab Cov Ntaub Ntawv Txog Cov Khoom Siv Kho Mob Sab Nraud thiab Cov Khoom Siv Rau Kev Tsis Muaj Cawv | Phau Ntawv Qhia Txog Cov Kws Muab Tshuaj | Cov Kws Muab Tshuaj Medi-Cal |
Hu rau DHCS
Cov lus nug lossis lus tawm tswv yim tuaj yeem xa mus rau lub thawv xa ntawv ntawm Pharmacy Benefits Division: medi-cal.pharmacybenefits@dhcs.ca.gov
1 California Welfare and Institutions Code Seem 14105.45
2 Daim Ntawv Cai Lij Choj Sib Tham 97 Kaum Feem Pua Kev Txo Nqi Rau Cov Tshuaj | DHCS