Medi-Cal Rx: Hloov Medi-Cal Pharmacy Services los ntawm Managed Care mus rau Nqi-Rau-Service Cov Lus Nug nquag​​ 

Version 16.0​​ 

Lub yim hli ntuj 31, 2023​​ 

The following Frequently Asked Questions (FAQs) document provides additional guidance and clarification to Medi-Cal beneficiaries, providers, plan partners, and other interested parties regarding the transition of Medi-Cal’s pharmacy benefit (collectively referred to as “Medi-Cal Rx”). As the Department of Health Care Services (DHCS) receives additional questions, this document will be updated as indicated by the version number and date on the title page.​​  

For information regarding Medi-Cal Rx, please visit DHCS’ dedicated Medi-Cal Rx Transition website. In addition, general questions regarding Medi-Cal Rx may also be submitted to DHCS via email at medi-cal.pharmacybenefits@dhcs.ca.gov.​​ 

Cov Lus Qhia​​ 

Cov ntaub ntawv dav dav​​ 
Cov ntaub ntawv yuav khoom​​ 
Hloov ntaub ntawv​​ 
Cov ntaub ntawv pub, Electronic Access, & Lwm yam kev pab kho mob​​ 
Muab Kev Tshaj Tawm, Kev Kawm, & Kev cob qhia​​ 
Cov neeg tau txais txiaj ntsig Kev Pabcuam Cov Neeg Siv Khoom & Cov Kev Pabcuam ntsig txog​​ 
Kev tsim nyog tau txais txiaj ntsig, sib faib cov nqi, thiab lwm yam lus nug ntsig txog kev noj qab haus huv​​ 
Medi-Cal Fee-For-Service Reimbursement Methodology​​ 
Kev txiav txim siab txog txoj cai​​ 
Kev Tso Cai Ua Ntej / Siv Kev Tswj Xyuas​​ 
340B Federal Drug Discount Program​​ 
Medi-Cal Rx Kev Tsis Txaus Siab / Kev Tsis Txaus Siab Kev daws teeb meem & Cov txheej txheem thov rov hais dua​​ 
Kev cuam tshuam txog nyiaj txiag / kev soj ntsuam​​ 
Lwm yam / Lwm Cov Ntaub Ntawv​​ 

Cov ntaub ntawv dav dav​​ 

1. Vim li cas Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS) tau hloov pauv lub tsev muag tshuaj Medi-Cal tau txais txiaj ntsig los ntawm Medi-Cal tswj hwm kev saib xyuas mus rau tus nqi them rau kev pabcuam?​​ 

DHCS transitioned Medi-Cal pharmacy services from the Medi-Cal managed care delivery system to the Medi-Cal fee-for-service delivery system as a result of Governor Gavin Newsom’s January 7, 2019 Executive Order N-01-19, for the purpose of achieving cost-savings for drug purchases made by the state, to standardize the pharmacy benefit statewide for all Medi-Cal members, and to increase overall access by allowing members to receive pharmacy services from the broader fee-for-service pharmacy network. In addition, this standardization is a critical step for the success of the California Advancing and Innovating Medi-Cal (CalAIM) initiatives being proposed by DHCS. For more information on CalAIM, visit the DHCS’ website.​​ 

2. Medi-Cal Rx yog dab tsi?​​ 

Medi-Cal Rx yog lub npe Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS) tau muab rau cov kev pabcuam hauv khw muag tshuaj thiab cov kev pabcuam uas tau tswj hwm los ntawm tus nqi them-rau-kev pabcuam xa los ntawm Magellan Medicaid Administration, LLC (MMA) raws li tag nrho Assumption of Operations (AOO).​​  

3. Puas yog tag nrho Medi-Cal Rx Assumption of Operations (AOO) sawv cev li cas?​​ 

Medi-Cal Rx AOO sawv cev rau hnub Magellan Medicaid Administration, LLC (MMA) tau txais lub luag haujlwm ua haujlwm rau tag nrho cov kev tswj xyuas tseem ceeb uas tsim nyog los txhawb Medi-Cal Rx, suav nrog tab sis tsis txwv rau kev tswj hwm, kev tso cai ua ntej (PA) thiab kev tswj hwm kev siv (UM), cov kev pabcuam thiab cov tswvcuab txhawb nqa, thiab lwm yam kev pabcuam ntxiv thiab tshaj tawm. Medi-Cal Rx puv AOO, raws li tau piav qhia hauv nqe lus nug #23-25, tau tshwm sim rau lub Ib Hlis 1, 2022. Yog xav paub ntxiv, thov mus saib cov lus nug #28-30.​​ 

4. Dab tsi yog qhov zoo ntawm kev hloov pauv Medi-Cal cov kev pab cuam hauv khw muag tshuaj los ntawm kev tswj hwm kev saib xyuas mus rau tus nqi-rau-kev pabcuam?​​ 

Kev hloov chaw muag tshuaj los ntawm Medi-Cal tswj kev saib xyuas mus rau tus nqi-rau-kev pabcuam yuav, thiab lwm yam:​​ 

• Ua raws li Medi-Cal lub tsev muag tshuaj tau txais txiaj ntsig thoob plaws lub xeev, nyob rau hauv ib qho kev xa khoom.​​ 
• Improve access to pharmacy services with a pharmacy network that includes the vast majority of the state’s pharmacies and is generally more expansive than individual Medi-Cal Managed Care Plan (MCP) pharmacy networks.​​ 
• Siv cov kev tswj hwm kev siv thoob plaws xeev (UM) cov txheej txheem rau txhua yam tshuaj kho mob sab nraud, raws li qhov tsim nyog.​​ 
• Strengthen California’s ability to negotiate state supplemental drug rebates with drug manufacturers as the largest Medicaid program with more than 15 million members.​​ 

5. Puas yog DHCS yuav tsum tau nrhiav kev pom zoo los ntawm tsoomfwv los siv Medi-Cal Rx?​​ 

Yog lawm. DHCS tau thov tsoomfwv pom zoo los ntawm Lub Chaw Pabcuam Medicare thiab Medicaid (CMS) txhawm rau hloov pauv cov txiaj ntsig ntawm lub tsev muag tshuaj los ntawm kev tswj hwm tus menyuam mus rau tus nqi-rau-kev pabcuam los ntawm CalAIM Tshooj 1915(b) wavier daim ntawv thov. Daim ntawv thov zam no cuam tshuam txog kev tshem tawm cov txiaj ntsig ntawm lub tsev muag tshuaj uas raug them los ntawm lub tsev muag tshuaj ntawm lub tsev muag tshuaj daim ntawv thov suav nrog cov tshuaj them rau cov neeg mob sab nraud thiab cov kws kho mob siv tshuaj, raws li tau piav qhia hauv Medi-Cal Rx Txhua Daim Ntawv Npaj (APL20-020), pib lub Ib Hlis 1, 2022.​​ 

6. Dab tsi Medi-Cal Managed Care Plans (MCPs) yog dab tsi thiab tsis cuam tshuam los ntawm Medi-Cal Rx?​​ 

Tag nrho Medi-Cal MCPs, suav nrog AIDS Healthcare Foundation, raug cuam tshuam. Medi-Cal Rx tsis siv rau Cov Kev Pabcuam Txhua-Inclusive Care for the Elderly (PACE), Senior Care Action Network (SCAN), lossis Major Risk Medical Insurance Program (MRMIP).​​ 

7. Will Medi-Cal Rx apply to California Children’s Services (CCS) and the Genetically Handicapped Persons Program (GHPP)? If yes, will Medi-Cal Rx change CCS, and how does it intend to address CCS-unique issues?​​ 

Medi-Cal Rx siv tau rau CCS thiab GHPP. Txij li thaum Medi-Cal Rx tag nrho Assumption of Operations (AOO), txhua qhov kev thov rau kev tso cai ua ntej (PAs) (Kev Thov Kev Tso Cai Kev Pabcuam lossis Daim Ntawv Tso Cai Kho Mob, raws li txoj cai) - rau ob lub nroog ywj pheej thiab nyob ruaj khov, thiab CCS-tsuas yog, GHPP nkaus xwb, thiab CCS/GHPP cov tswv cuab Medi-Medi-Cal - txheej txheem los ntawm cov kws muag tshuaj.​​ 

Raws li tau sau tseg hauv nqe lus nug #24 hauv qab no, DHCS tswj hwm tag nrho cov kev pab them nqi tshuaj thiab kev lav phib xaub txoj cai nrog rau kev teeb tsa txhua yam cuam tshuam rau PA kev txiav txim siab. Tsis tas li ntawd, paub txog cov kev xav tau tshwj xeeb ntawm kev saib xyuas kev noj qab haus huv ntawm CCS / GHPP cov pej xeem, DHCS tseem ua haujlwm ze thiab koom tes nrog CCS Pawg Kws Pab Tswv Yim thiab lwm cov neeg muaj feem cuam tshuam hauv qhov chaw no.​​ 

8. Dab tsi yuav tsis hloov raws li ib feem ntawm Medi-Cal Rx?​​ 

Medi-Cal Rx tsis hloov cov hauv qab no:​​ 

• The scope of the existing Medi-Cal pharmacy benefit.​​ 
• Kev muab cov kev pabcuam hauv tsev muag tshuaj raws li ib feem ntawm cov qauv sau nqi / tag nrho suav nrog hauv ib qho chaw kho mob lossis Lub Sijhawm Ntev (LTC) (suav nrog Cov Kws Pabcuam Saib Xyuas Neeg Mob [SNFs] thiab lwm yam Kev Pabcuam Nruab Nrab [ICFs]), tsis hais txog kev xa khoom.​​ 
• Medi-Cal uas twb muaj lawm cov chaw muag tshuaj uas tswj xyuas kev kho mob carve-outs (piv txwv li, ntshav yam, tshuaj tiv thaiv kab mob HIV/AIDS, tshuaj tiv thaiv kev puas hlwb, lossis tshuaj siv los kho cov teeb meem siv yeeb tshuaj).​​ 
• Txhua qhov kev pabcuam hauv tsev muag tshuaj uas raug nqi raws li kev khomob thiab / lossis kev thov hauv tsev tsis yog kev thov tshuaj.​​ 
• Txoj Kev Ncaj Ncees Hauv Xeev (SFH), raws li tau hais tseg hauv California txoj cai lij choj uas siv tau.​​ 

9. Medi-Cal Rx cuam tshuam li cas rau kev them nyiaj ntawm cov tshuaj uas tau muab rau hauv qhov chaw kho mob hauv tsev lossis mus sij hawm ntev (LTC)?​​ 

Raws li tau sau tseg hauv nqe lus nug #8, yog tias muab tshuaj los ua ib feem ntawm cov nqi them rau cov kev pabcuam muab los ntawm LTC/Skilled Nursing Facility (SNF), ces nws yuav yog lub luag haujlwm ntawm Medi-Cal Managed Care Plan (MCP). Tsis tas li ntawd, yog tias cov tshuaj noj tsis yog ib feem ntawm cov nqi them rau cov kev pabcuam muab los ntawm LTC / SNF, thiab hloov pauv raws li tus nqi-rau-kev pabcuam, ces lub luag haujlwm nyiaj txiag rau cov tshuaj no yog txiav txim los ntawm hom kev thov uas lawv tau them. Yog tias cov tshuaj raug xa tawm los ntawm lub tsev muag tshuaj thiab tau them rau hauv lub tsev muag tshuaj thov, ces lawv raug muab tshem tawm thiab them los ntawm Medi-Cal Rx. Yog tias cov tshuaj tau muab los ntawm LTC / SNF thiab tau them rau ntawm daim ntawv kho mob / tsev kho mob, MCP yog lub luag haujlwm, lossis California Medicaid Management Information System (CA-MMIS) Kev Pabcuam Nyiaj Txiag, yog tias tus tswvcuab them nqi rau kev pabcuam.​​ 

10. What pharmacy benefits will be “carved out” of Medi-Cal managed care due to Medi-Cal Rx?​​ 

Medi-Cal Rx tau tuav lub luag haujlwm los ntawm Medi-Cal Managed Care Plans (MCPs) rau kev tswj xyuas cov hauv qab no thaum lub tsev muag tshuaj tau them nqi ntawm lub tsev muag tshuaj thov:​​ 

• Cov Tshuaj Kho Mob Sab Nraud, suav nrog qee yam Tshuaj Kho Mob (PADs)​​ 
• Cov khoom siv kho mob tshwj xeeb​​ 
• Khoom noj khoom haus Enteral​​ 

Cov tshuaj muaj nyob rau hauv cov kev pab cuam uas tsis yog capitated rau MCPs (piv txwv li, ntshav yam, tshuaj HIV/AIDS, antipsychotics, los yog tshuaj siv los kho cov teeb meem siv yeeb tshuaj) nyob twj ywm uncapitated (carved) tsis hais hom kev thov (uas yog, khw muag tshuaj los yog daim ntawv thov kho mob). Cov ntaub ntawv kho mob rau cov chav kawm ntawm cov tshuaj no yuav tsum tau xa mus ntxiv raws li kev thov them nqi rau kev pabcuam rau Medi-Cal Fiscal Intermediary (FI). Cov kws kho mob tau ceeb toom tias cov tshuaj tsis tau teev nyob rau hauv lub tsev muag tshuaj Daim Ntawv Cog Lus Tshuaj (CDL) thiab tswj hwm los ntawm
tus kws kho mob uas tsis yog kws kho mob yuav tsum tau them nqi raws li cov ntaub ntawv kho mob los ntawm tus kws kho mob thiab tsis raug them los ntawm lub tsev muag tshuaj.​​ 

Cov tshiab ntxiv rau cov npe ntawm cov chav kawm tsis muaj npe ntawm cov tshuaj carve-out npe feem ntau siv sijhawm tsawg kawg 60 hnub ua ntej kev thov tuaj yeem ua tiav tiav. Cov kws kho mob tau hais kom tuav lawv cov lus thov kom txog thaum lub kaw lus npaj tau txais lawv.​​  

For more information, please see DHCS’ Medi-Cal Scope document located on the DHCS’ website. This document provides additional context and information related to DHCS’ implementation of the Medi-Cal managed care to fee-for-service pharmacy carve-out. It also provides an inventory of the Medi-Cal pharmacy benefit, characterized as either not subject to the carve-out (that is, those pharmacy benefits that are billed on medical and institutional claims) or subject to the carve-out (that is, all pharmacy benefits that are billed on pharmacy claims).​​ 

11. DHCS yuav ua li cas thiaj li tau txais kev pab them nqi kho mob rau cov ntshav qab zib, uas suav nrog cov ntawv xeem, lancets, glucometers, tswj kev daws teeb meem, thiab cov cuab yeej lancing, tom qab Medi-Cal Rx tag nrho Assumption of Operations (AOO)?​​ 

Cov kab mob ntshav qab zib mellitus (rau cov zis, ntshav qabzib, thiab ketones) thiab lancets txoj cai tau txais txiaj ntsig tsis tau hloov pauv raws li Medi-Cal Rx thiab raug rau cov npe ntawm cov khoom cog lus thiab cov qauv tam sim no tau tshaj tawm hauv Cov Khoom Siv Khomob ntawm Medi-Cal Cov Kev Pabcuam Phau Ntawv Qhia.​​  

Cov ntaub ntawv no muaj nyob rau hauv Medi-Cal Rx Tus Kws Kho Mob Phau Ntawv Qhia thiab ntawm Medi-Cal Rx Web Portal.​​ 

Cov Glucometers tshwj xeeb, Cov Txheej Txheem Tswjhwm, thiab Lancing Devices yog lub tsev muag tshuaj-them nqi kho mob tau txais txiaj ntsig los ntawm Medi-Cal Rx, pib txij Lub Ib Hlis Ntuj 1, 2022, thiab raug txwv rau cov khoom ntawm cov npe tshiab uas tau tsim los ntawm Covered Self-Monitoring Blood Glucose Systems (Glucometers), Control Solutions, thiab Web Lancing Cailable Devices (Rax) Medi-Cal R qhov kev txiav txim siab yog ib qho txiaj ntsig ntawm lub tsev muag tshuaj. Cov khoom siv hauv pawg no uas tsis nyob rau hauv daim ntawv teev npe no raug suav tias tsis tsim nyog rau kev saib xyuas los ntawm Medi-Cal Rx raws li cov txiaj ntsig ntawm lub tsev muag tshuaj.​​ 

Cov khoom lag luam uas tsis tau cog lus tsis pom nyob rau hauv Daim Ntawv Teev Kev Saib Xyuas Tus Kheej Cov Ntshav Qab Zib (Glucometers), Cov Txheej Txheem Tswjhwm, thiab Lancing Devices raug them rov qab los ntawm Medi-Cal Managed Care Plans (MCPs) lossis tus nqi-rau-kev pabcuam Kev Pabcuam Nyiaj Txiag (FI) raws li HCPCS-billed Durable Medical Equip. Kev txwv kom muaj nuj nqis tseem tsis hloov.​​ 

12. Tam sim no DHCS ua li cas thiaj li tau txais kev pab them nqi kho mob sab nraud cov tshuaj insulin (Omnipod thiab V-Go) thiab tau hloov pauv txij li Medi-Cal Rx tag nrho Assumption of Operations (AOO)?​​ 

Disposable Insulin Delivery Devices (DIDDs) are pharmacy-billed medical supply benefits through Medi-Cal Rx, effective January 1, 2022,and are restricted to the products on the List of Covered Disposable Insulin Delivery Devices on the Medi-Cal Rx Web Portal. These products are identified as “Partial” carve outs on the Medi‑Cal Rx Scope document; therefore, all DIDD claims billed on a pharmacy claim must be submitted to  Medi-Cal Rx, and HCPCS-billed medical claims must be submitted to either Medi-Cal Managed Care Plans (MCPs) or the fee-for-service Fiscal Intermediary (FI). NDC-billed claims submitted after the transition to Medi-Cal Rx for products not found on this list will be denied.​​ 

DIDDs xav tau kev tso cai ua ntej (PA) rau kev them nyiaj rov qab thiab cov txheej txheem tshwj xeeb raug siv. DIDDs suav nrog hauv txoj cai hloov pauv. Rau cov ntawv thov uas tau them dhau los ua cov txiaj ntsig kho mob tau sau rau hauv daim ntawv CMS-1500 , cov kws kho mob yuav tsum suav nrog PA ua ntej xa nrog daim ntawv thov nyiaj pab kho mob thiab sau ntawv pov thawj rau kev kho mob txuas ntxiv thaum lawv xa cov chaw muag tshuaj rau cov khoom thov kom ntseeg tau tias cov kev pab them nqi kho mob tau ua tiav.​​ 

13. DHCS ua li cas thiaj li tau txais kev pab them nqi kho mob txuas ntxiv mus (CGMs), lwm yam khoom siv kho mob ntev (DME), DME cov khoom siv thiab cov khoom siv kho mob pov tseg, tom qab Medi-Cal Rx tag nrho Assumption of Operations (AOO)?​​ 

Therapeutic CGM Systems became a pharmacy-billed medical supply benefit through Medi-Cal Rx, effective January 1, 2022. These products are identified as “Partial” carve outs on the Medi-Cal Rx Scope document. Therefore, a CGM pharmacy claim must be submitted to Medi-Cal Rx. CGM Systems are included under the Medi-Cal Rx Transition Policy. For claims previously paid as a medical benefit billed on a CMS-1500 form, documentation of the most recently paid medical claim, and written justification for continuation of therapy, should be included for the requested product to ensure that coverage requirements are met.​​ 

 Coverage is restricted to products on the List of Covered Therapeutic Continuous Glucose Monitoring (CGM) Systems and requires a Prior Authorization (PA) for reimbursement. Specific coverage criteria continue to apply. Refer to the List of Covered Therapeutic Continuous Glucose Monitoring (CGM) Systems and the Medi-Cal Rx Provider Manual on the Medi-Cal Rx Web Portal for specific information.​​ 

Rau Tus Nqi-rau-Service (FFS) Medi-Cal cov neeg tau txais txiaj ntsig, pib lub Kaum Hlis 1, 2022, cov lus thov uas tau them dhau los ua cov txiaj ntsig kho mob tau sau rau hauv daim ntawv CMS 1500 los ntawm HCPCS code yuav tsum raug xa mus raws li lub tsev muag tshuaj thov rau Medi-Cal Rx. Cov HCPCS cov lej no yuav tsis lees paub cov ntaub ntawv kho mob uas xa nrog hnub ua haujlwm tom qab Lub Kaum Ob Hlis 1, 2022.​​ 

Nco tseg: Cov twj tso kua tshuaj insulin sib raug rau qee cov khoom siv CGM tseem yuav nyob twj ywm DME cov nqi them raws li cov txiaj ntsig kho mob tau them rau ntawm CMS 1500 daim ntawv ntawm HCPCS code. Xa mus rau ntu DME ntawm Medi-Cal phau ntawv qhia chaw muag tshuaj ntawm Medi-Cal Cov Chaw Pabcuam lub vev xaib rau kev pab them nqi thiab cov ntaub ntawv them nqi ntawm DME insulin twj thiab khoom siv.​​ 

Medi-Cal Managed Care members should contact their individual Medi-Cal Managed Care Plan (MCP) as MCPs may determine their own CGM coverage policy, criteria, and reimbursement. CGM is a partially carved-out medical supply; therefore, MCPs can determine if they will continue to provide the benefit themselves or through Medi-Cal Rx. Managed care CGM coverage policies are available on the individual MCP’s website for provider and member clarification.​​ 

14. DHCS yuav ua li cas thiaj li yuav tau txais kev pab them nqi kho mob lwm yam kev pab cuam tam sim no lossis yav tas los them raws li daim ntawv thov kho mob, los ntawm HCPCS code thiab hauv daim ntawv CMS-1500, tom qab Medi-Cal Rx tag nrho Assumption of operations (AOO)?​​ 

Unless otherwise noted on the Medi-Cal Rx Scope Document, all other Durable Medical Equipment (DME) and DME supplies continue, unchanged, and reimbursable as an HCPCS-billed DME benefit through the fee-for-service Fiscal Intermediary (FI), on a medical claim.​​ 

Sterile Syringes with Needles (non-insulin), a disposable medical supplies item currently billed via HCPCS code on a CMS-1500 form, will become a pharmacy-billed medical supply benefit through Medi-Cal Rx, effective January 1, 2022, restricted to products on the newly created List of Covered Sterile Syringes with Needles (non-insulin), which can be found on the Medi-Cal Rx Web Portal. NDC‑billed claims submitted after transitioning to Medi-Cal Rx for products not found on this list will be denied. These products are identified as “Partial” on the Medi‑Cal Rx Scope document; therefore, claims billed on a pharmacy claim must be submitted to Medi-Cal Rx, and claims billed as HCPCS-billed medical claims must be submitted to either Medi-Cal Managed Care Plans (MCPs) or the fee-for-service Fiscal Intermediary. Restrictions will remain unchanged: 200 syringes every 30 days without prior authorization.​​ 

Alcohol Prep Pads, a disposable medical supplies item, are a pharmacy-billed medical supply benefit through Medi-Cal Rx. These products are identified as “Partial” on the Medi-Cal Rx Scope document; therefore, claims billed on a pharmacy claim must be submitted to Medi-Cal Rx, and claims billed as HCPCS-billed medical claims must be submitted to either Medi-Cal MCPs or the fee-for-service FI. Alcohol swab sticks are not included in this category and are not a Medi-Cal Rx benefit. Alcohol swab sticks will continue to be reimbursable as an HCPCS-billed medical supplies benefit through the
fee-for-service FI.​​ 

15. Puas yog Medi-Cal Rx suav nrog cov nyiaj pab hauv tsev muag tshuaj uas tau them rau kev kho mob thiab/lossis kev thov hauv tsev?​​ 

No, since the Medi-Cal Rx full Assumption of Operations (AOO), Medi-Cal pharmacy services billed on a medical or institutional claim by a pharmacy, or any other provider, continue to be billed through either Medi-Cal Managed Care Plans (MCPs) or to the California Medicaid Management Information System (CA-MMIS) Fiscal Intermediary, for either Medi-Cal MCP members or fee-for-service members, as they were prior to the Medi-Cal Rx full AOO. However, drugs that are “carved out” of the managed care delivery system (for example, blood factor, HIV/AIDS drugs, antipsychotics, or drugs used to treat substance use disorder) will be billed to CA-MMIS for both fee-for-service and MCP members.​​ 

16. Are COVID-19 vaccines “carved out” of Managed Care Plans (MCPs)?​​ 

Consistent with the approach being taken by Medicare through Medicare Advantage Plans, the Department of Health Care Services (DHCS) carves out the COVID-19 vaccine from Medi-Cal MCPs and reimburses providers under the fee-for-service delivery system for both medical and pharmacy claims. This approach eases program administration, eliminates challenges with
out-of-network provider reimbursements, and keeps vaccine administration fee rates consistent for providers regardless of delivery system.​​  

17. Medi-Cal yuav them nyiaj rov qab li cas rau kev tswj hwm cov tshuaj tiv thaiv COVID-19?​​ 

Medi-Cal reimburses the associated COVID-19 vaccine administration fee at the allowable Medicare rate for all claims (medical, outpatient, and pharmacy) based on the number of required doses. As the federal government pays for the initial vaccines, there is no Medi-Cal provider reimbursement for the COVID-19 vaccine itself. However, the cost of the vaccine will be reimbursed once COVID-19 vaccines become commercialized in Fall 2023. For more information about the COVID-19 vaccine, visit https://covid19.ca.gov/ and the Department of Health Care Services’ (DHCS) COVID-19 Response web page.​​  

18. Where can I find DHCS’ guidance and coverage/reimbursement policy relative to the COVID-19 vaccine?​​ 

Refer to the COVID-19 Vaccines, OTC Antigen Test Kits, and Therapeutics: Coverage and Reimbursements section of the Medi-Cal Rx Provider Manual for DHCS’ policy and reimbursement guidance on COVID-19 vaccines.​​ 

For additional information about COVID-19, visit https://covid19.ca.gov/ and DHCS’ COVID-19 Response web page.​​  

19. Are COVID-19 Over The Counter Self-Administered Antigen Tests “carved out” of Managed Care Plans (MCPs)?​​ 

The Department of Health Care Services’ (DHCS) coverage of COVID-19 OTC Self-Administered Antigen Tests as a pharmacy-billed benefit through Medi-Cal Rx was effective February 1, 2022, in accordance with current Centers for Disease Control and Prevention (CDC) recommendations. Quantity limitations and specific product coverage criteria apply. For additional information, visit the Medi-Cal Rx Provider Portal via the Medi-Cal Rx Web Portal and refer to the Covered Emergency Use of Authorization (EUA) COVID-19 Antigen Tests list on the Forms & Information page, or refer to the Over‑the‑Counter (OTC)COVID-19 Antigen Test Kits section of the Medi-Cal Rx Provider Manual.​​ 

Cov ntaub ntawv yuav khoom​​ 

20. Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv tau tswj hwm Medi-Cal Rx li cas?​​ 

DHCS tau tshaj tawm Daim Ntawv Thov Kev Pom Zoo (RFP) #19-96125 thaum Lub Yim Hli 22, 2019, txhawm rau muab ib tus neeg ua haujlwm pabcuam kev pabcuam los tswj hwm Medi-Cal tus nqi-rau-kev pabcuam chaw muag tshuaj rau, thaum lub sijhawm, ntau dua 13.5 lab tus tswvcuab Medi-Cal. Thaum Lub Kaum Ob Hlis 13, 2019, DHCS tau muab daim ntawv cog lus rau Magellan Medicaid Administration, LLC (MMA) los muab cov kev pabcuam dav dav ntawm kev tswj hwm raws li tau hais los ntawm DHCS, uas suav nrog tab sis tsis txwv rau kev tswj hwm, kev tso cai ua ntej (PA) thiab kev tswj xyuas kev siv tshuaj (UM), kev tswj hwm tshuaj noj tshuaj, thiab lwm yam kev pabcuam kev pabcuam rau cov tswvcuab. Medi-Cal kev pab kho mob.​​ 

21. Medi-Cal Rx lub sijhawm yuav khoom yog dab tsi?​​ 

Lub sijhawm ncua sij hawm rau Medi-Cal Rx kev siv zog ntsig txog kev yuav khoom yog raws li hauv qab no:​​  

• Lub Xya Hli 22, 2019: Draft Medi-Cal Rx Thov Kev Pom Zoo (RFP) #19-96125 tso tawm rau ob lub lis piam tawm tswv yim rau pej xeem.​​ 
• Lub Yim Hli 22, 2019: Kawg Medi-Cal Rx RFP #19-96125 tso tawm.​​ 
• Lub Yim Hli 29, 2019: Qhov Kawg Medi-Cal Rx RFP #19-96125 cov lus nug vim yog Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS).​​ 
• Lub Cuaj Hlis 17, 2019: Cov lus teb rau cov lus nug ntsig txog Qhov Kawg Medi-Cal Rx RFP #19-96125 thiab cov ntawv ntxiv tau tshaj tawm.​​ 
• Lub Kaum Hli 1, 2019: Tag nrho Medi-Cal Rx RFP #19-96125 cov lus thov yuav raug them.​​ 
• Kaum Ib Hlis 7, 2019: Daim Ntawv Ceeb Toom Txog Kev Npaj Siab Tshaj Tawm rau DHCS lub vev xaib.​​ 
• Lub Kaum Ob Hlis 13, 2019: DHCS tau txais daim ntawv cog lus rau Magellan Medicaid Administration, LLC (MMA).​​ 
• Kaum Ob Hlis 20, 2019: Hnub Kawg Ua Ntawv Thov.​​ 
• January 1, 2022: Medi-Cal Rx Full Assumption of Operations (AOO) took place.​​ 

22. Leej twg yog Medi-Cal Rx tus neeg cog lus xaiv los ntawm txoj kev yuav khoom?​​ 

Medi-Cal Rx Tus Neeg Ua Haujlwm tau xaiv los tswj Medi-Cal tus nqi-rau-kev pabcuam chaw muag tshuaj yog Magellan Medicaid Administration, LLC (MMA).​​ 

23. What roles and responsibilities will Medi-Cal Managed Care Plans (MCPs) maintaining upon Medi-Cal Rx’s full Assumption of Operations (AOO)?​​ 

Medi-Cal MCPs yuav muaj lub luag haujlwm rau cov haujlwm suav nrog, tab sis tsis txwv rau, cov hauv qab no:​​ 

• Saib xyuas thiab tswj xyuas txhua yam dej num tsim nyog rau kev koom tes hauv Medi-Cal kev saib xyuas cov tswv cuab thiab cov dej num muaj feem xyuam, ua raws li cov lus cog tseg.​​ 
• Muab kev saib xyuas thiab kev tswj hwm ntawm txhua qhov chaw kho mob ntawm chaw muag tshuaj, suav nrog kev muab kab mob thiab kev tswj hwm tshuaj.​​ 
• Kev ua haujlwm thiab kev them nyiaj ntawm tag nrho cov kev pabcuam hauv lub tsev muag tshuaj uas tau them nyiaj rau kev kho mob thiab tsev kho mob.​​ 
• Koom nrog cov rooj sib tham uas cuam tshuam nrog Medi-Cal Ntiaj Teb Kev Tshuaj Xyuas Tshuaj Siv Tshuaj (DUR) Pawg Thawj Coj thiab Lwm Lub Tsev Haujlwm Saib Xyuas Kev Kho Mob (DHCS)-cov rooj sib tham pawg kws muag tshuaj.​​ 
• Kev koom tes txuas ntxiv thiab tsis tu ncua hauv kev txiav txim tom qab kev txiav txim siab DUR cov haujlwm xws li Retrospective DUR (RetroDUR) (raws li qhov tsim nyog rau kev sib koom tes saib xyuas), cov kev kawm, thiab xa daim ntawv tshaj tawm DUR txhua xyoo.​​ 

24. What roles and responsibilities will DHCS maintain upon Medi-Cal Rx’s full Assumption of Operations?​​ 

DHCS yuav yog lub luag haujlwm rau cov haujlwm suav nrog, tab sis tsis txwv rau, cov hauv qab no:​​ 

• Tsim, siv, thiab tswj txhua txoj cai ntawm Medi-Cal lub tsev muag tshuaj, suav nrog, tab sis tsis txwv rau:​​ 
  • Kev pab tshuaj​​ 
  • Lub xeev cov tshuaj ntxiv nyiaj rov qab​​ 
  • Kev tso cai ua ntej (PA) / tswj kev siv (UM)​​ 
• Kev sib tham ntawm, thiab kev cog lus rau, lub xeev cov nyiaj rov qab tshuaj ntxiv.​​ 
• Reviewing and issuing final determinations regarding all PA denials for Medi-Cal Rx benefits, including those for California Children’s Services (CCS) program/Genetically Handicapped Persons Program (GHPP).​​ 
• Muab kev saib xyuas ntawm, thiab kev txhawb nqa rau, Lub Xeev Lub Rooj Sib Hais Ncaj Ncees (SFH) txheej txheem.​​ 
• Tsim kom muaj Medi-Cal Rx cov txheej txheem them nyiaj rov qab hauv tsev muag tshuaj, ua raws li lub xeev thiab tsoomfwv cov cai.​​ 
• Tsim thiab tswj hwm Medi-Cal lub chaw muag tshuaj network.​​ 
• Saib xyuas Medi-Cal Ntiaj Teb Tshuaj Siv Tshuaj Ntsuam Xyuas (DUR) Pawg Neeg Saib Xyuas thiab lwm pab pawg kws muag tshuaj, koom tes nrog Magellan Medicaid Administration, LLC (MMA).​​ 
• Daim ntawv cog lus tswj thiab saib xyuas / saib xyuas ntawm MMA.​​ 

25. What roles and responsibilities will the Medi-Cal Rx Contractor assume upon Medi-Cal Rx’s full Assumption of Operations?​​ 

Magellan Medicaid Administration, LLC (MMA) yuav yog lub luag haujlwm rau cov haujlwm suav nrog, tab sis tsis txwv rau, cov hauv qab no:​​  

• Muab Medi-Cal Rx Lub Chaw Pabcuam Cov Neeg Siv Khoom (CSC) uas muaj 24 teev hauv ib hnub, 7 hnub hauv ib lub lis piam, 365 hnub hauv ib xyoos, tsis suav cov hnub so uas tau pom zoo, lossis tshwj tsis yog hais qhia los ntawm Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS), txhawm rau txhawb txhua tus kws kho mob thiab cov tswv cuab hu, nrog rau kev nthuav qhia, kev cob qhia, thiab cov ntaub ntawv qhia.​​ 
• Muab Medi-Cal Managed Care Plan (MCP) ncaj qha rau kev sib koom tes nrog kev saib xyuas thiab teeb meem kho mob.​​ 
• Providing real-time access into MMA’s electronic environment via a secure portal to all Medi-Cal providers (prescribers and pharmacies) and MCPs, Mental Health Plans, and Substance Use Disorder Plans.​​ 
• Muab cov ntaub ntawv thov kev tswj hwm, kev ua haujlwm, thiab kev them nyiaj ua haujlwm rau txhua qhov kev pabcuam hauv khw muag tshuaj uas tau them rau hauv daim ntawv thov tshuaj.​​ 
• Saib xyuas kev sib koom tes ntawm cov txiaj ntsig (COB) nrog rau lwm qhov kev pab them nqi kho mob, suav nrog Medicare.​​ 
• Providing utilization management (UM) functionalities, including ensuring pharmacy prior authorization (PA) adjudication occurs within 24 hours, inclusive of California Children’s Services (CCS) program/Genetically Handicapped Persons Program (GHPP).
  Note: All pharmacy PA denials will require DHCS’ review prior to final determination.​​ 
• Muab Cov Kev Pabcuam Yav Tom Ntej thiab Kev Siv Tshuaj Rov Qab (DUR).​​ 
• Muab cov ntaub ntawv pub (tsawg kawg txhua hnub) rau Medi-Cal MCPs los txhawb lawv lub luag haujlwm ntawm kev koom tes saib xyuas cov tswv cuab, ua raws li kev kho mob ntawm chaw muag tshuaj, thiab kev tswj kab mob thiab tshuaj.​​ 
• Providing drug rebate administration services that are compliant with federal and state laws and adhere to DHCS’ policies and direction.​​ 

Between January 1, 2021, and Medi-Cal Rx’s full Assumption of Operations (AOO) on January 1, 2022, DHCS – in partnership with MMA – provided various Medi-Cal Rx Transitional Supports and services (TSS), as outlined in greater detail below in questions #30 and #31.​​ 

26. Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv ua li cas kom ntseeg tau tias Medi-Cal Rx Tus Neeg Ua Haujlwm tsis siv cov ntaub ntawv tus neeg mob, suav nrog cov ntaub ntawv sau tshuaj, rau lwm lub hom phiaj uas tsis yog Medi-Cal Rx cov kev pabcuam kev tswj hwm?​​ 

The requirements for appropriate use of Medi-Cal member information are outlined, clearly and in detail, in Medi-Cal Rx Request for Proposal (RFP) #19-96125, which becomes part of the final executed contract language. In addition, Magellan Medicaid Administration, LLC (MMA) is required to adhere to all existing state and federal requirements as well as DHCS’ policies relating to sensitive data and privacy.​​ 

27. Kuv tuaj yeem nrhiav tau cov ntaub ntawv ntau ntxiv txog Medi-Cal Rx Thov Kev Pom Zoo #19-96125?​​ 

Yog xav paub ntxiv txog Medi-Cal Rx Thov Kev Pom Zoo #19-96125, thov mus saib hauv FI$Cal/Cal eProcure lub vev xaib. Cov ntawv thov zaum kawg yuav dhau los ntawm Lub Kaum Hli 1, 2019 thaum 4 teev tsaus ntuj PDT. Cov txheej txheem kev yuav khoom tam sim no raug kaw.​​ 

Hloov ntaub ntawv​​ 

28. Thaum twg Medi-Cal Rx tag nrho Assumption of Operations (AOO) yuav tshwm sim?​​ 

Medi-Cal Rx full AOO, as described in questions #23-25, inclusive of claims administration and prior authorization adjudication functionalities, will took place January 1, 2022.​​  

29. Why was the planned Go-Live date of April 1, 2021 for Medi-Cal Rx’s full Assumption of Operations delayed?​​ 

The Department of Health Care Services (DHCS) delayed the planned Go-Live date of April 1, 2021, for Medi-Cal Rx because of the need to review new conflict avoidance protocols submitted by Magellan Medicaid Administration, LLC (MMA), the project’s contracted vendor.​​ 

Thaum Lub Ib Hlis 2021, Centene Corporation tshaj tawm tias nws npaj yuav tau Magellan. Centene ua haujlwm - los ntawm cov chaw ua haujlwm - Managed Care Plans (MCPs) thiab cov khw muag tshuaj uas koom nrog Medi-Cal. Qhov kev hloov pauv no tsis tau xav txog thiab yuav tsum tau muaj sijhawm ntxiv rau kev tshawb nrhiav cov txheej txheem tiv thaiv kev tsis sib haum xeeb los xyuas kom meej tias muaj cov foob pob hluav taws uas tau txais los ntawm cov koom haum koom tes los tiv thaiv cov chaw muag tshuaj cov ntaub ntawv ntawm txhua tus tswv cuab Medi-Cal, thiab tiv thaiv lwm cov ntaub ntawv ntiag tug.​​ 

Medi-Cal Rx remains of utmost importance to the State of California as a tool to standardize the Medi-Cal pharmacy benefit statewide under one delivery system. Medi-Cal Rx applies statewide utilization management (UM) protocols to all outpatient drugs, standardizing the experience for all Medi-Cal members and providers. Medi-Cal Rx also strengthens California’s ability to negotiate state supplemental drug rebates with drug manufacturers, helping to reduce pharmaceutical costs.​​ 

30. Did Medi-Cal Rx use a “phased” approach to transition services?​​ 

No, full implementation of Medi-Cal Rx took place on January 1, 2022. However, between January 1, 2021, and Medi-Cal Rx full Assumption of Operations (AOO), the Department of Health Care Services (DHCS), in partnership with Magellan Medicaid Administration, LLC (MMA), provided various Medi-Cal Rx Transitional Supports and Services (TSS), including but not limited to:​​ 

• Tso cai rau Medi-Cal cov chaw muab kev pab, Managed Care Plans (MCPs), thiab lwm tus neeg txaus siab sau npe rau Medi-Cal Rx ruaj ntseg portals thiab koom nrog cov kev cob qhia uas ua kom muaj kev nkag siab ntau dua ntawm qhov project thiab txhawb kev npaj ua haujlwm rau cov kws kho mob thiab MCPs.​​ 
• Sawv ntsug thiab txhawb nqa Medi-Cal Rx Lub Chaw Pabcuam Cov Neeg Siv Khoom (CSC) kom tso cai rau cov kws tshaj lij ntawm CSC los teb thiab teb cov lus nug los ntawm Medi-Cal cov tswvcuab, cov kws khomob, MCPs, thiab lwm tus neeg txaus siab, uas tuaj yeem ua rau muaj kev tsis sib haum xeeb thiab lwm yam teeb meem tshwm sim thaum ua tiav tag nrho ntawm Medi-Cal Rx. Thaum CSC cov kws tshaj lij tsis tau muab tag nrho cov kev pabcuam ua ntej AOO, lawv tau tom qab
  Medi-Cal Rx puv AOO. Lawv muaj peev xwm muab TSS tseem ceeb, suav nrog kev tshaj tawm rau cov neeg muab kev pabcuam, nrog rau cov phiaj xwm kev pabcuam thiab cov ntaub ntawv tseem ceeb, txheeb ze rau Medi-Cal Rx cov cuab yeej thiab cov haujlwm ua haujlwm.​​ 
• Muab sijhawm ntxiv rau MCPs los cuam tshuam nrog thiab tsim kev sib tham nrog rau Medi-Cal Rx cov kws kho mob tshwj xeeb, uas tau pab MMA tsim kom raug thiab ua tiav MCP cov ntaub ntawv los xyuas kom meej tias cov kev xav tau ntawm tus kheej ntawm cov neeg tau txais kev pab los ntawm txhua tus MCP txuas ntxiv mus.​​ 
• Allowed DHCS and MMA to roll out additional Medi-Cal Rx website and secure portal functionalities and tools in advance of Medi-Cal Rx full AOO, including, but not limited to, the Medi-Cal Rx Pharmacy Locator tool,
  Medi-Cal Rx Provider Manual, Medi-Cal Rx Contract Drugs List (CDL), and other related policy and programmatic information.​​ 

Tom qab Medi-Cal Rx tag nrho AOO, MMA tau lav lub luag haujlwm rau tag nrho cov kev pabcuam kev tswj hwm uas tseem tshuav tsim nyog los txhawb Medi-Cal Rx, suav nrog, tab sis tsis txwv rau, cov hauv qab no:​​ 

• Txuas CSC cov sij hawm mus rau 24 teev hauv ib hnub, 7 hnub hauv ib lub lis piam, 365 hnub hauv ib xyoos, tsis suav nrog cov hnub caiv pom zoo, lossis tshwj tsis yog hais los ntawm DHCS, los txhawb txhua tus neeg muab kev pabcuam thiab cov tswvcuab hu, nrog rau kev tshaj tawm, kev cob qhia, thiab cov ntaub ntawv qhia.​​ 
• Kev lees paub kev tswj hwm, kev tso cai ua ntej (PA) thiab kev tswj hwm kev siv (UM), cov kev pabcuam thiab cov tswvcuab txhawb nqa, thiab lwm yam kev pabcuam ntxiv thiab tshaj tawm.​​  

Yog xav paub ntxiv, thov mus saib cov lus nug #23-25.​​ 

31. DHCS tau ua li cas kom ntseeg tau tias kev paub thiab kev paub dhau los ntawm Medi-Cal Managed Care Plans (MCPs), thiab lwm tus neeg muaj feem cuam tshuam, tau txais txiaj ntsig hauv cov txheej txheem hloov pauv kom ua tiav cov kev pabcuam txuas mus ntxiv?​​ 

DHCS tau koom tes nrog cov neeg sab nraud hauv ntau txoj hauv kev thiab los ntawm ntau txoj hauv kev los xyuas kom meej tias kev paub thiab kev paub dhau los ua kom Medi-Cal Rx ua tiav. DHCS npaj siab yuav txuas ntxiv cov hom kev sib koom tes no thiab cog lus tias yuav ua haujlwm nrog nws cov neeg koom tes sab nraud, suav nrog Medi-Cal MCPs, cov nroog, cov chaw muab kev pabcuam, cov neeg txhawb nqa cov neeg siv khoom, thiab cov neeg tau txais txiaj ntsig, kom ntseeg tau tias muaj kev hloov pauv thiab ua tiav. Piv txwv li, DHCS tau tsim ib lub koom haum Medi-Cal MCP Workgroup thiab Medi-Cal Rx Advisory Workgroup uas muaj ntau tus neeg sawv cev ntawm cov neeg sawv cev uas tau ntsib tsis tu ncua los tham txog ntau yam teeb meem, txheeb xyuas cov kev coj ua zoo tshaj plaws, thiab muab cov kev daws teeb meem thiab cov tswv yim los txhawb DHCS cov kev siv zog.​​ 

Mus rau tom ntej, DHCS tseem yuav txuas ntxiv mus tshawb nrhiav cov hauv kev los txhim kho thiab txhim kho cov neeg koom nrog kev koom tes thiab kev txhawb nqa thoob plaws Medi-Cal, uas yuav suav nrog cov phiaj xwm Medi-Cal Rx pawg neeg ua haujlwm cov rooj sib tham thiab kev sib tham los sib koom tes ntawm cov kev coj ua zoo tshaj plaws thiab cov tswv yim ua kom tau raws li cov kev xav tau ntawm txhua tus neeg muaj kev cuam tshuam.​​ 

32. Cov ntaub ntawv hais txog kev hloov pauv ntawm Medi-Cal Rx thiab lwm yam kev hloov pauv yuav raug xa mus li cas?​​ 

DHCS yuav koom tes nrog MMA kom ntseeg tau tias txhua tus neeg txaus siab (xws li, tab sis tsis txwv rau, Medi-Cal MCPs, Cov Kev Pab Cuam Rau Kev Puas Hlwb, Cov Kev Npaj Siv Tshuaj, cov neeg muab kev pab, thiab cov neeg tau txais txiaj ntsig) raug ceeb toom txog kev hloov pauv thiab lwm yam kev hloov pauv.​​ 

Kev sib txuas lus yuav raug tshaj tawm los ntawm ntau txoj hauv kev suav nrog, tab sis tsis txwv rau, cov hauv qab no:​​ 

• Medi-Cal Rx Web Portal tshiab tau tsim tawm thaum Lub Rau Hli 2020 thiab ua lub platform los qhia thiab sib txuas lus muaj peev xwm, cov ntaub ntawv, thiab kev hloov pauv rau cov neeg nyiam. Cov ntsiab lus kev kawm thiab cov lus nug nquag raug tshaj tawm thiab hloov kho tsis tu ncua.​​ 
• Pib txij lub Rau Hli 2020, Medi-Cal Rx Subscription Service (MCRxSS) tau tsim muaj los ntawm Medi-Cal Rx Web Portal kom tso cai rau cov neeg txaus siab sau npe thiab tau txais Medi-Cal Rx hloov tshiab los ntawm email.​​ 
• Txij thaum Lub Yim Hli 2020 mus ntxiv, cov neeg txaus siab tuaj yeem pom cov ntawv xov xwm hais txog kev hloov pauv ntawm Medi-Cal Rx Web Portal.​​ 
• Muaj cov kev cob qhia thiab cov ntaub ntawv qhia kev kawm rau Medi-Cal cov kws kho mob thiab MCPs muaj los ntawm Medi-Cal Rx lub vev xaib tshiab. MCPs thiab cov kws kho mob muaj peev xwm sau npe rau kev cob qhia thiab kev kawm cov xwm txheej txij li lub Cuaj Hli 2020.​​ 
• Cov ntawv ceeb toom rau cov neeg tau txais txiaj ntsig Medi-Cal nyob rau hauv ob qho tib si MCPs thiab them nqi-rau-kev pabcuam xa tuaj rau lossis txog Lub Kaum Hli 1, 2020, Kaum Ib Hlis 1, 2020, thiab Lub Kaum Ob Hlis 15, 2020. Cov ntawv ceeb toom rau cov neeg tau txais txiaj ntsig Medi-Cal kuj tau xa tuaj pib thaum lub Peb Hlis 2021 kom qhia lawv txog kev ncua mus rau Medi-Cal Rx tag nrho Assumption of Operations (AOO). Cov ntawv ceeb toom ntxiv rau cov neeg tau txais txiaj ntsig Medi-Cal tau xa tuaj rau lossis txog lub Kaum Ib Hlis 1, 2021, tshaj tawm AOO thaum Lub Ib Hlis 1, 2022.​​ 
• Medi-Cal MCP Medi-Cal Rx Kev Tshaj Tawm Kev Tshaj Tawm, ua los ntawm kev sib tw hu xovtooj sab nraud lossis lwm yam kev sib txuas lus, raws li kev pom zoo los ntawm DHCS, rau cov tswvcuab rau npe.​​ 
• Hloov tshiab rau Medi-Cal Managed Care Plan Cov Tswv Cuab Phau Ntawv Qhia (Cov Ntaub Ntawv Pov Thawj), nrog rau cov ntaub ntawv qhia rau lwm lub koom haum cuam tshuam.​​ 
• Kev hloov kho tshiab rau Medi-Cal Phau Ntawv Qhia Txog Tus Kws Kho Mob, nrog rau cov kev taw qhia tshiab thiab cov ntaub ntawv luam tawm los ntawm MMA, raws li DHCS qhia.​​ 
• Hloov kho rau Medi-Cal MCP cov ntawv cog lus, raws li xav tau, txhawm rau cuam tshuam txog kev hloov pauv ntawm lub tsev muag tshuaj tau txais txiaj ntsig los ntawm kev tswj hwm kev saib xyuas mus rau tus nqi-rau-kev pabcuam.​​ 
• Tsim ib daim ntawv tshiab Medi-Cal Rx Txhua Daim Ntawv Npaj rau MCPs, thiab lwm cov ntawv ceeb toom muaj feem xyuam rau cov chaw muab kev pabcuam hauv nroog thiab lwm tus neeg koom tes tseem ceeb hauv lub nroog.​​ 
• Tsim ib Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv tshiab Txhua Daim Ntawv Npaj, txheeb ze rau Medi-Cal Rx, rau Medi-Cal MCPs uas muab kev taw qhia los ntawm kev tswj hwm, kev ua raws, thiab kev xa ntawv xa mus.​​ 
• Hloov tshiab rau Medi-Cal MCP tus nqi.​​ 
• Regular updates via existing stakeholder processes and workgroups, including but not limited to DHCS’ bimonthly Stakeholder Communication Update, Medi‑Cal Rx Public Forum, Medi-Cal Global Drug Use Review Board, Medi-Cal Pharmacy Directors’ Meeting, Stakeholder Advisory Committee, California Children’s Services Advisory Committee, etc.​​ 

33. DHCS yuav ua li cas kom cov neeg tau txais txiaj ntsig Medi-Cal hloov mus rau Medi-Cal Rx tsis muaj kev cuam tshuam hauv lawv txoj kev saib xyuas thiab/lossis tsis muaj peev xwm nkag mus rau cov tshuaj uas tsim nyog?​​ 

To assist Medi-Cal beneficiaries, providers (prescribers and pharmacies), and Managed Care Plans (MCPs) with the Medi-Cal Rx full Assumption of Operations (AOO), DHCS will provide various Medi-Cal Rx Transitional Supports and Services (TSS) between January 1, 2021, through Medi-Cal Rx full AOO on January 1, 2022, as described in more detail in question #30 above and has developed and will implement a multi-faceted pharmacy transition policy. The pharmacy transition policy will use strategies such as “grandfathering” previously approved prior authorization (PA) requests through their stated duration, not to exceed one (1) full year from the date the prescription was written, unless the drug is included in the list of exceptions allowing for extended/multi-year PAs up to five (5) years for certain drug classes/categories. The transition period also includes a 180-day period where DHCS will not require PA for existing prescriptions without previously approved PAs from their applicable Medi-Cal MCPs, for drugs not on the Medi-Cal Contract Drugs List (CDL), or that otherwise have PA requirements under Medi-Cal Rx. This policy does not apply to new prescriptions or drugs that do not have PA requirements under Medi-Cal Rx. During this transition period, Magellan will provide system messaging, reporting and outreach to provide for a smooth transition to Medi-Cal Rx. This pharmacy transition period will facilitate a smooth, productive transition, ensuring that Medi-Cal beneficiaries do not experience disruption in their access to medically necessary prescriptions while maintaining compliance with all state and federal laws related to the Medi-Cal pharmacy benefit. DHCS’ Pharmacy Transition Policy is available on the Medi-Cal Rx Transition webpage.​​ 

34. DHCS puas yuav tsim kho Medi-Cal Rx txoj kev hloov pauv, thiab, yog tias muaj, cov phiaj xwm yuav suav nrog dab tsi?​​ 

Yog lawm, ua raws li cov kev cai uas tau teev tseg hauv Daim Ntawv Thov Kev Pom Zoo #19-96125, Exhibit A, Attachment I – Scope of Work – Takeover, Magellan Medicaid Administration, LLC (MMA) thiab DHCS yuav tsim kho Medi-Cal Rx lub chaw muag tshuaj hloov mus kom ze/txoj kev npaj kom suav nrog, yam tsawg kawg, txheej txheem rau:​​ 

• Muab kev ceeb toom txaus thiab yooj yim rau Medi-Cal cov khw muag tshuaj thiab cov kws kho mob kom ua txhua yam tsim nyog los ua kom haum rau Medi-Cal Rx Tus Neeg Ua Haujlwm tshiab, Medi-Cal Daim Ntawv Cog Lus Tshuaj (CDL), thiab cov txheej txheem cuam tshuam.​​ 
• Muab cov ntawv ceeb toom tsim nyog thiab cov ntaub ntawv muaj feem cuam tshuam los ntawm DHCS thiab Medi-Cal Managed Care Plans (MCPs) rau cov neeg tau txais txiaj ntsig Medi-Cal txog kev hloov pauv.​​ 
• Muab kev taw qhia kom tau txais kev tso cai ua ntej (PA) ntawm cov tshuaj uas tau muab xa mus rau lub sijhawm hloov pauv los ntawm kev tso cai txuas mus ntxiv (kev kho tshuaj tau pib ua ntej Medi-Cal Rx tag nrho Assumption of Operations [AOO]) cov tshuaj yuav tsum tau muab xa mus thiab them nqi yam tsis tau tso cai PA ua ntej. Txawm li cas los xij, kev tshuaj xyuas yav tom ntej Kev Siv Tshuaj (DUR) cov cai rau kev nyab xeeb tshuaj yuav tseem siv tau.​​ 
• Lub tsev muag tshuaj, tus kws kho mob, thiab cov neeg tau txais kev pab, suav nrog kev ua kom cov tog neeg cuam tshuam tau txais kev ceeb toom tsim nyog ntawm, thiab cov ntaub ntawv ntxiv ntsig txog, Medi-Cal Rx lub sijhawm hloov pauv ntawm lub tsev muag tshuaj thiab cov txheej txheem cuam tshuam.​​ 

35. DHCS yuav siv cov tswv yim dab tsi hauv Medi-Cal Rx txoj kev hloov pauv los ua kom muaj kev hloov pauv mus rau Medi-Cal Rx kom muaj txiaj ntsig zoo rau cov neeg tau txais txiaj ntsig?​​ 

To assist Medi-Cal beneficiaries with the full Medi-Cal Rx transition, DHCS will provide various Medi-Cal Rx Transitional Supports and Services (TSS) between January 1, 2021, through Medi-Cal Rx full Assumption of Operations (AOO) on January 1, 2022, as described in more detail in question #30 above. In addition, DHCS’ pharmacy transition policy, as described in question #33 above, and in more detail in the link below, will use strategies such as the following:​​ 

• “Grandfathering” previously approved prior authorizations (PAs) through their stated duration, not to exceed one (1) full year from the date the prescription was written, unless the drug is included in the list of exceptions allowing for extended/multi-year PAs up to five (5) years for certain drug classes/categories, as articulated in the policy.​​ 

For more information, please review DHCS’ Pharmacy Transition Policy on the Medi-Cal Transition webpage.​​ 

36. Puas yog Medi-Cal Managed Care Plans (MCPs) yuav tsum txiav thiab/lossis tsis muaj kev tso cai ua ntej (PAs) uas raug txiav txim thiab pom zoo los ntawm Medi-Cal MCP rau lossis ua ntej Medi-Cal Rx tag nrho Assumption of Operations (AOO)?​​ 

Tsis yog, Medi-Cal MCPs yuav tsum tsis txhob tso tseg thiab/lossis tsis muaj PAs li no thiab yuav tsum zoo ib yam li tsis muaj kev tso cai cia li yuav tas ib hnub ua ntej Medi-Cal Rx puv AOO. Ob lub DHCS thiab Medi-Cal MCPs yuav tsum ua cov kauj ruam tsim nyog los xyuas kom cov neeg tau txais txiaj ntsig Medi-Cal txuas ntxiv tau txais cov txiaj ntsig thiab cov kev pab cuam kho mob uas tsim nyog rau lub tsev muag tshuaj thaum hloov mus rau Medi-Cal Rx.​​ 

Cov ntaub ntawv pub, Electronic Access, & Lwm yam kev pab kho mob​​ 

37. Puas yog Medi-Cal Rx muab cov ntaub ntawv muag tshuaj thiab kev siv hluav taws xob tsim nyog rau Medi-Cal cov kws kho mob, Medi-Cal Managed Care Plans (MCPs), thiab lwm lub koom haum los txhawb kev sib koom tes saib xyuas?​​ 

Yog lawm, Medi-Cal Rx yuav muab cov ntaub ntawv pub (tsawg kawg txhua hnub) rau Medi-Cal MCPs los txhawb lawv lub luag haujlwm ntawm kev koom tes saib xyuas cov neeg tau txais txiaj ntsig, ua raws li kev kho mob ntawm chaw muag tshuaj, thiab kev tswj kab mob thiab tshuaj. DHCS tseem tab tom tshawb nrhiav cov kev xaiv thiab cov lus pom zoo uas cuam tshuam rau cov ntaub ntawv pub rau Kev Noj Qab Haus Huv Kev Noj Qab Haus Huv thiab Kev Siv Tshuaj Tsis Zoo thiab yuav koom nrog cov neeg muaj feem tseem ceeb hauv qhov chaw no. Ib qho kev daws teeb meem uas pom zoo yuav raug muab coj los siv tom qab Medi-Cal Rx tag nrho Assumption of Operations.​​ 

Tsis tas li ntawd, Medi-Cal Rx yuav muab kev nkag mus rau hauv lub sijhawm tiag tiag rau hauv MMA qhov chaw hluav taws xob los ntawm lub portal ruaj ntseg rau txhua tus kws kho mob Medi-Cal (cov kws kho mob thiab cov khw muag tshuaj) thiab Medi-Cal MCPs, Mental Health and Substance Use Disorder Plans, thiab ntxiv cov koom haum raws li DHCS.​​ 

38. Medi-Cal Rx yuav muab kev pab cuam kho mob thiab kev saib xyuas dab tsi ntxiv rau Medi-Cal Managed Care Plans (MCPs)?​​ 

MMA yuav muab kev pab cuam kho mob thiab kev saib xyuas ntxiv rau Medi-Cal MCPs kom ua tau raws li lawv cov kev cog lus cog lus ntsig txog kev saib xyuas cov neeg tau txais txiaj ntsig Medi-Cal, kev ua raws li kev noj tshuaj, thiab lwm yam kev lav phib xaub, los ntawm:​​ 

• Providing a dedicated Medi-Cal MCP clinical liaison team to interface with the Medi-Cal MCPs, other MMA staff, and MMA’s portal/environment to assist with and resolve clinical pharmacy-related issues for Medi-Cal Rx, including those involving prior authorization, as directed by DHCS.​​ 
• Tuav cov neeg ua haujlwm kom txaus ntawm Medi-Cal MCP kev sib tham hauv chaw kho mob kom paub meej tias qib kev nkag mus tau raug tswj xyuas rau Medi-Cal MCPs.​​ 
• Providing access to the Medi-Cal MCP clinical liaisons through Medi-Cal Rx’s dedicated Integrated Voice Response system to assist and resolve clinical pharmacy-related issues.​​ 

For more information, please see the Medi-Cal Rx MCP Clinical Liaison Policy and the Medi-Cal Rx Website and Pharmacy Portal Policy.​​ 

Muab Kev Tshaj Tawm, Kev Kawm, & Kev cob qhia​​ 

39. Hom kev nthuav qhia twg, kev kawm, thiab kev cob qhia, nrog rau cov kev txhawb nqa uas muaj feem xyuam, yog DHCS muab thiab/los yog npaj ua rau Medi-Cal Rx?​​ 

DHCS, koom tes nrog MMA, tau mob siab rau muab Medi-Cal tus neeg muab kev pab txhawb nqa cov neeg siv khoom, suav nrog tab sis tsis txwv rau cov hauv qab no:​​ 

• Lub Chaw Pabcuam Cov Neeg Siv Khoom (CSC) los txhawb txhua tus neeg muab kev pabcuam hu, nees nkaum plaub (24) teev hauv ib hnub, xya (7) hnub hauv ib asthiv, peb puas rau caum-tsib (365) hnub hauv ib xyoos, tsis suav cov hnub so pom zoo, lossis tshwj tsis yog tias DHCS tau qhia lwm yam.​​ 
• Kev nthuav qhia, kev cob qhia, thiab cov ntaub ntawv qhia rau Medi-Cal cov kws kho mob, Medi-Cal Managed Care Plans (MCPs), thiab lwm qhov chaw.​​ 
• Cov kev pabcuam hauv Web los txhawb kev sib txuas lus thiab cov cuab yeej rau Medi-Cal Rx.​​ 
• Real-time access into MMA’s electronic environment via a secure portal.​​ 
• Lwm cov kev pabcuam thiab kev txhawb nqa los ua kom muaj kev hloov pauv tau zoo thiab muaj txiaj ntsig (xws li Medi-Cal Rx cov kev pabcuam hloov pauv hloov pauv thiab cov kev pabcuam (TSS) thiab 180-hnub lub sijhawm hloov pauv lub tsev muag tshuaj).​​ 

Tsis tas li ntawd, MMA's Medi-Cal Rx CSC Cov Neeg Sawv Cev yuav ua sawv cev ntawm DHCS los xa thiab muab cov kev txawj ntse / kev txhawb nqa txog Medi-Cal Rx cov ntaub ntawv thiab cov ntaub ntawv cob qhia rau cov kws kho mob (cov kws kho mob thiab cov khw muag tshuaj) cov chaw muag tshuaj, thiab cov koom tes npaj, hauv ntau qhov chaw. Yog xav paub ntxiv, thov mus saib Daim Ntawv Thov Kev Pom Zoo #19-96125 Exhibit A, Attachment II – Scope of Work – Operations – Education and Outreach.​​ 

Additional information about provider outreach, education, and training, including schedules and sign-up information, is and will be made available on DHCS’ dedicated Medi-Cal Rx Web Portal. In addition, providers and all other interested parties are encouraged to sign up for the Medi-Cal Rx Subscription Service (MCRxSS) to receive news and updates related to Medi-Cal Rx.​​ 

Kev Pabcuam Tswvcuab Cov Neeg Siv Khoom & Cov Kev Pabcuam ntsig txog​​ 

39. Yam dab tsi ntawm Medi-Cal cov neeg tau txais kev pabcuam thiab cov kev txhawb nqa muaj feem cuam tshuam yog DHCS muab thiab/los yog npaj ua rau Medi-Cal Rx?​​ 

DHCS, koom tes nrog Magellan Medicaid Administration, LLC (MMA), tau mob siab rau muab cov tswv cuab cov neeg siv khoom thiab kev txhawb nqa, suav nrog tab sis tsis txwv rau cov hauv qab no:​​ 

• Medi-Cal Rx Lub Chaw Pabcuam Cov Neeg Siv Khoom (CSC) txhawb nqa txhua tus tswvcuab hu, 24 teev hauv ib hnub, 7 hnub hauv ib asthiv, 365 hnub hauv ib xyoos, tsis suav cov hnub so uas pom zoo, lossis tshwj tsis yog DHCS qhia lwm yam.​​ 
• Qhia cov ntaub ntawv ntsig txog Medi-Cal Rx los ntawm ntau txoj hauv kev, suav nrog tab sis tsis txwv rau cov ntawv ceeb toom tsim nyog ntawm US Mail thiab cov kev pabcuam hauv web (piv txwv li, cov vev xaib sab nraud los txhawb kev sib txuas lus thiab cov cuab yeej rau Medi-Cal Rx).​​ 
• The Medi-Cal Rx Pharmacy Locator (PLT) tool is available on the
  Medi-Cal Rx Web Portal and includes all Medi-Cal Rx eligible pharmacies.​​ 
• Ib qho kev sib tham sib lub suab teb (IVR) system los muab:​​ 
  • Cov ntaub ntawv kaw tseg​​ 
  • Kev xaiv kev pabcuam tus kheej​​ 
  • Muaj peev xwm thov rov qab los ntawm kev pabcuam cov neeg siv khoom, xws li kev hu xovtooj rov qab lossis cov ntaub ntawv muab los ntawm kev xa ntawv lossis email.​​ 

In addition, MMA’s Customer Service Representatives (CSRs) act on behalf of DHCS to relay and provide subject-matter expertise/support regarding
Medi-Cal Rx information and related materials to Medi-Cal members, in a variety of venues. For more information, see Request for Proposal (RFP)
#19-96125 Exhibit A, Attachment II – Scope of Work – Operations – Education and Outreach.​​ 

Kev Tsim Nyog Rau Cov Tswv Cuab, Kev Sib Koom Tus Nqi, & Lwm Cov Lus Nug Txog Kev Noj Qab Haus Huv​​ 

40. Relative to the transition to Medi-Cal Rx, what happens to the claims if a beneficiary’s eligibility is in “on-hold” status and is waiting for the county to adjust the beneficiary’s eligibility?​​ 

The “on-hold” status pertains to the beneficiary’s Medi-Cal Managed Care Plan eligibility status and there is no change to this process under Medi-Cal Rx. Medi‑Cal Rx will be evaluating the Health Care Plan (HCP) status in the Medi-Cal Eligibility Data System (MEDS) to determine an active versus inactive status and proceed accordingly.​​ 

41. Relative to Medi-Cal Rx, what happens if the beneficiary has moved and the county has not updated the beneficiary’s eligibility?​​ 

There is no change to Medi-Cal’s overarching eligibility processes as a result of the transition to Medi-Cal Rx. Medi-Cal Rx will be evaluating the Health Care Plan (HCP) status in the Medi-Cal Eligibility Data System (MEDS) to determine an active versus inactive status and proceed accordingly.​​ 

42. Are there any changes to Medi-Cal’s Share of Cost (SOC) policy where self-pay and spend-down have to occur before the Medi-Cal benefits?​​ 

Medi-Cal’s overarching SOC policy is not changing, and associated processes and policies would remain unchanged under Medi-Cal Rx.​​ 

43. Thaum twg cov neeg tau txais txiaj ntsig Medi-Cal muaj Lwm Qhov Kev Pabcuam Kev Noj Qab Haus Huv (OHC), qhov kev pab them nqi kho mob thiab cov nyiaj pab twg yog qhov tseem ceeb?​​ 

Medi-Cal’s overarching OHC policy is not changing and, in most instances, Medi‑Cal is the payer of last resort.​​ 

44. Medi-Cal Rx puas yuav cuam tshuam rau Medi-Cal cov neeg tau txais txiaj ntsig uas muaj Medi-Cal thiab Medicare (Part D)?​​ 

Tsis yog. Medi-Cal Rx tsis cuam tshuam lossis hloov lwm yam kev pab them nqi tshuaj rau Medi-Cal cov neeg tau txais txiaj ntsig uas muaj Medi-Cal thiab Medicare (Part D). Medi-Cal tej zaum yuav them cov txiaj ntsig tshuaj noj uas Medicare (Part D) tsis tuaj yeem, yog li Medi-Cal cov neeg tau txais txiaj ntsig yuav tsum tau tham nrog lawv cov kws kho mob.​​ 

Medi-Cal Fee-For-Service Reimbursement Methodology​​ 

45. Rau Medi-Cal cov khw muag tshuaj, Medi-Cal tus nqi them-rau-kev pab cuam lub tsev muag tshuaj li cas yog txoj kev them rov qab, thiab dab tsi yog cov khoom?​​ 

DHCS utilizes drug reimbursement methodologies as defined in state law and the Medi-Cal State Plan. Medi-Cal fee-for-service pharmacy reimbursement is the lower of the drug’s ingredient cost plus a professional dispensing fee or pharmacy’s usual and customary charge to the public.​​ 

1. Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS) suav cov nqi tshuaj muaj nqis raws li qhov qis tshaj ntawm:​​ 
   • Tus Nqi Them Nqi Them Nqi Hauv Tebchaws (NADAC) ntawm cov tshuaj, lossis thaum tsis muaj NADAC, Tus Nqi Muag Khoom Muag Khoom Muag (WAC) + 0%, lossis​​ 
   • Federal Upper Limit (FUL), los yog​​ 
   • Tus Nqi Tshaj Lij Tshaj Lij Tshaj Lij Tshaj Lij Tshaj Lij (MAIC).​​ 
2.  Tus nqi them tus kws tshaj lij (ob-tiered raws li tag nrho Medicaid thiab tsis yog Medicaid txhua xyoo lub tsev muag tshuaj thov ntim [uas yog, cov tshuaj muab tshuaj]):​​ 
   • > los yog = 90,000 thov ib xyoos: $10.05​​ 

For 340B claims, reimbursement is covered entity’s actual drug acquisition cost plus the appropriate professional dispensing fee.​​ 

For more information on the Departments MAIC program, view the Maximum Allowable Ingredient Cost (MAIC) Program Frequently Asked Questions.​​ 

46. Does the Department of Health Care Services (DHCS) reimburse specialty pharmacies for medication management services provided to patients identified as “high-risk” for compliance, adherence, or medication misuse concerns?​​ 

DHCS has established the Medication Therapy Management (MTM) program as authorized in Welfare and Institutions Code (W&I Code) Section 14132.969 as part of pharmacist services to support, ensure continued access, and reimburse specialty pharmacies for the services which they offer. Part of this is establishing and maintaining a list of covered specialty drug categories, eligibility criteria, and conditions for which MTM pharmacist services will be reimbursed. DHCS contracts with any willing Medi-Cal enrolled pharmacy providers, as authorized in W&I Code, Section 14105.3, to provide MTM pharmacist services to Medi-Cal members for covered specialty drug categories and to patients that meet the eligibility criteria in the contracts. For additional details, see DHCS’ web page Update on Medication Therapy Management Pharmacy Services.[NI1]​​  

 [NI1]The last question # 48 in V15 has been deleted in this version​​ 

Kev txiav txim siab txog txoj cai​​ 

47. What is Medi-Cal’s Contract Drugs List (CDL)?​​ 

The Department of Health Care Services (DHCS) maintains the CDL, which is DHCS’ list of covered drugs and includes drugs for which there is a current state supplemental drug rebate agreement in place. Generally, under the existing Medi-Cal fee-for-service pharmacy benefit, if a drug is listed on the CDL, then it does not require an approved prior authorization (PA) for coverage. Alternatively, if a drug is not listed on the CDL, then it would require an approved PA for coverage. Note that even if a drug is listed on the CDL, it may still require an approved PA for coverage; however, if a certain drug on the CDL requires an approved PA, then DHCS’ policy would clearly articulate that requirement.​​ 

View the CDLs on the Contract Drugs List page on the Medi-Cal Rx Web Portal.​​ 

48. How will Medi-Cal Rx affect Medi-Cal’s Contract Drugs List (CDL), and does DHCS take anything else into consideration for its Medi-Cal drug coverage policies?​​ 

Medi-Cal RxCDL replaced the previous DHCS-approved Medi-Cal CDL as the list of covered drugs. In addition, DHCS’ pharmacy drug coverage policies take into consideration:​​ 

• Tag nrho US Food and Drug Administration (FDA)-pom zoo cov tshuaj tiv thaiv kab mob sab nraud, raws li tau hais los ntawm Lub Chaw rau Medicare & Medicaid Services (CMS), raug rau kev kho mob.​​ 
• DHCS’ business rules that detail requirements for the covered outpatient drugs and non-drug products, and limitations of coverage, which include aid code, program, and/or date-specific coverage.​​ 
• 
  View the CDLs on the Contract Drugs List page on the Medi-Cal Rx Web Portal.
  ​​ 

49. Will Medi-Cal Rx consider local exceptions to Medi-Cal’s Contract Drugs List (CDL)?​​ 

No. Medi-Cal Rx uses a single, statewide, and Department of Health Care Services (DHCS)-approved CDL to standardize the Medi-Cal pharmacy benefit. View the CDLs on the Contract Drugs List page on the Medi-Cal Rx Web Portal.​​ 

50. DHCS ua li cas txiav txim siab ntxiv lossis tshem tawm cov tshuaj los ntawm Daim Ntawv Cog Lus Tshuaj (CDL)?​​ 

DHCS tuaj yeem ntxiv cov tshuaj rau Medi-Cal CDL raws li tau txais los ntawm (1) Ib qho kev thov rau Tus Neeg Siv Tshuaj Sab Nraud (IDP) los ntawm lub chaw tsim khoom, tus kws kho mob, thiab / lossis tus kws muag tshuaj, lossis (2) DHCS-initiated IDP tshuaj xyuas, yog tias tsim nyog. Thaum tau txais daim IDP lawm, DHCS ua qhov kev tshuaj xyuas dav dav ntawm qhov kev thov, suav nrog cov ntaub ntawv pov thawj, kev coj ua zoo tshaj plaws hauv kev lag luam, thiab cov qauv tshuaj xyuas hauv qab no, uas tau teev tseg hauv Welfare and Institutions Code Section 14105.39(c)(1) thiab (2):​​ 

• Kev nyab xeeb ntawm cov tshuaj​​ 
• Qhov ua tau zoo ntawm cov tshuaj​​ 
• Qhov tseem ceeb xav tau ntawm cov tshuaj​​ 
• Lub peev xwm rau kev siv tshuaj tsis raug​​ 
• Tus nqi ntawm cov tshuaj rau qhov kev pab cuam​​ 

In addition to conducting its own internal review, DHCS also consults with the Medi-Cal Drug Advisory Committee (Committee), as required by Welfare and Institutions Code Section 14105.4. The Committee is composed of members who are appointed by DHCS’ Director – including community physicians and pharmacists, faculty members from academic pharmacy institutions, and Medi-Cal beneficiaries – and assists DHCS by providing written recommendations to inform decision-making regarding adding and/or deleting, drug(s) from the Medi-Cal CDL. The Committee’s final response with detailed, drug-by-drug recommendations is due within 30 calendar days of DHCS requesting consultation, and takes into consideration the Welfare and Institutions Code Section 14105.39(c)(1) and (2) criteria, as well as additional information such as generic name, brand name, federal Food and Drug Administration (FDA)-approved indications, manufacturer, fiscal/cost impact, clinical criteria, etc.​​ 

DHCS then makes an informed and documented decision whether or not to add the drug to the Medi-Cal CDL based upon the Committee’s recommendations, state law requirements, and other relevant factors.​​ 

As DHCS moves closer to Medi-Cal Rx’s full Assumption of Operations on January 1, 2022, it is continuing its efforts to closely analyze variances and gaps between Medi-Cal Managed Care Plan (MCP) formularies and the Medi-Cal CDL. As a product of DHCS’ analysis, and in an effort to drive down the total number of required prior authorizations, numerous medications have been added to the Medi-Cal CDL since January 2020, and DHCS will continue this review on a monthly basis to add more medications to the Medi-Cal CDL.​​ 

51. Puas muaj cov kev cai lij choj hloov pauv cuam tshuam txog Medi-Cal Rx?​​ 

Yes, DHCS’ proposed Trailer Bill language was part of the Governor’s Fiscal Year 2020-21 budget, which made the following changes:​​ 

• Repealed the six-prescription (“6 Rx”) drug limit.​​ 
• Tshem tawm Medi-Cal tus nqi-rau-kev pab them nqi kho mob.​​ 
• Redefined “Best Price” for Medi-Cal drugs to allow for drug prices outside the United States to be considered for state supplemental drug rebate contracts.​​ 

52. Rau cov tshuaj uas xav tau kev tso cai ua ntej (PA), cov kws kho mob lossis cov kws kho mob puas yuav tsum tau xa daim ntawv PA txhua zaus muab tshuaj?​​ 

Tsis yog, PA tuaj yeem them rau ntau qhov kev xa tawm hauv lub sijhawm PA pom zoo.​​ 

53. Puas yog DHCS tau hloov txoj cai los tso cai rau ntau xyoo ua ntej kev tso cai (PA)?​​ 

To reduce administrative burden while ensuring continuation of care and medication safety for members, DHCS has enabled extended duration/multi-year PAs for up to five years for certain maintenance medications used for chronic conditions. Qualified prescriptions are automatically extended. See the Extended Duration Prior Authorizations for Maintenance Medications alert for additional information.​​ 

54. Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS) puas yuav txiav txim siab hloov txoj cai tswjfwm kom tso cai rau kev txhim kho thiab/lossis nthuav dav nws txoj kev txiav txim plaub ntug?​​ 

Raws li ib feem ntawm Medi-Cal Rx, DHCS txuas ntxiv txhim kho thiab/lossis nthuav dav kev txiav txim siab nws tus kheej (piv txwv li, kev tso cai thov kev tso cai thiab them nyiaj) kom txo tau cov tshuaj uas tau tso cai ua ntej (PA) cov cai uas yuav tsum tau tshuaj xyuas phau ntawv.​​ 

55. Puas yog Medi-Cal Rx suav nrog cov kev pabcuam kev tswj hwm opioid?​​ 

Medi-Cal Rx provides opioid management services in accordance with House Resolution 6 Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act,​​ 

Medi-Cal pharmacy policy and procedures, and clinically appropriate, evidence-based guidelines. To promote transparency and increased awareness, the Department of Health Care Services (DHCS) has shared this information externally at various stakeholder events, including but not limited to the Medi-Cal Rx Managed Care Plan (MCP) workgroup and
Medi-Cal Rx Advisory workgroup. For more information regarding DHCS’ current pharmacy policies and procedures in this space, see the reference resource.​​ 

Tsis tas li ntawd, raws li ib feem ntawm Medi-Cal Rx, DHCS tau thov cov lus pom zoo raws li ib feem ntawm Daim Ntawv Thov Kev Pom Zoo (RFP) txhawm rau tshawb nrhiav kev txhim kho kev tswj hwm kev siv tshuaj opioid uas mus rau saum toj thiab tshaj qhov yuav tsum tau los ntawm tsoomfwv txoj cai lij choj. Mus rau pem hauv ntej, DHCS yuav txiav txim siab siv cov kev pabcuam kev tswj hwm opioid zoo dua.​​  

56. Medi-Cal Rx puas yuav suav nrog qhov kev pab cuam hauv tsev muag tshuaj?​​ 

The Department of Health Care Services (DHCS) did not implement a lock-in program as part of the Medi-Cal Rx full Assumption of Operations (AOO) on January 1, 2022, but will evaluate options with Magellan Medicaid Administration, LLC (MMA) in the future. As part of the Medi-Cal Rx Request for Proposal (RFP) #19-96125, DHCS solicited proposals to explore further pharmacy lock-in program options, including, but not limited to, things such as: use of multiple pharmacies, different prescribers of controlled substances, and number of controlled substances. In addition, DHCS is aware that approximately 50 percent of Medi-Cal Managed Care Plans (MCPs) utilize pharmacy lock-in programs today, so through stakeholder engagement efforts, DHCS will be looking to learn more and utilize best practices for
Medi-Cal Rx.​​ 

57. Kuv tuaj yeem nrhiav Medi-Cal Rx Txhua Daim Ntawv Npaj Rau Medi-Cal Managed Care Plans (MCPs) uas muab kev taw qhia los ntawm txoj cai thiab kev pom zoo?​​ 

DHCS’ new Medi-Cal All Plan Letter APL 20-020 for Medi-Cal MCPs can be found on DHCS’ website.​​ 

58. Kuv tuaj yeem nrhiav Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv Txhua Tus Daim Ntawv Npaj, txheeb ze rau Medi-Cal Rx, rau Medi-Cal Managed Care Plans (MCPs) uas muab kev taw qhia los ntawm kev tswj hwm, kev ua raws, thiab kev xa mus?​​ 

The DMHC All Plan Letter APL 20-035 relative to Medi-Cal Rx is available on the Department of Managed Health Care’s website.​​ 

59. Where can I find the Informational Notice (IN) for the California Children’s Services (CCS) program and the Genetically Handicapped Persons Program (GHPP) relative to Medi-Cal Rx?​​ 

The IN 20-03 for CCS and GHPP programs relative to Medi-Cal Rx is available on DHCS’ website.​​ 

60. Kuv tuaj yeem nrhiav Daim Ntawv Ceeb Toom Txog Tus Cwj Pwm Kev Noj Qab Haus Huv (BHIN) qhov twg uas muab cov lus qhia ntsig txog Medi-Cal Rx rau kev noj qab haus huv hauv lub nroog thiab Kev Siv Tshuaj Yeeb (SUD)?​​ 

The BHIN that provides guidance related to Medi-Cal Rx for county mental health and Substance Use Disorder services is currently under development and, once finalized, we will be available on the Behavioral Health Information Notices page on DHCS’ website.​​  

Kev Tso Cai Ua Ntej / Siv Kev Tswj Xyuas​​ 

61. Raws li Medi-Cal Rx, kev thov kev tso cai ua ntej (PA) yuav raug tshuaj xyuas thiab txiav txim li cas?​​ 

DHCS shall, in collaboration with MMA, process PA requests and provide a response to the submitting provider within 24 hours of receiving a PA request, pursuant to Welfare and Institutions Code Section 14133.37. A more detailed process document is posted on DHCS’ Medi-Cal Rx Transition website. ​​ 

62. Puas yog Medi-Cal Managed Care Plans (MCPs) puas raug tso cai rau daim ntawv cog lus nrog Medi-Cal Rx tus neeg cog lus ua daim ntawv tso cai ua ntej (PA)?​​ 

Tsis tau. Txij li thaum Medi-Cal MCPs yuav tsis raug cog lus rau lub tsev muag tshuaj Medi-Cal cov txiaj ntsig ntxiv lawm tom qab Medi-Cal Rx tag nrho Assumption of Operations rau Lub Ib Hlis Ntuj 1, 2022, tag nrho cov kev txiav txim siab PA thiab cov txheej txheem cuam tshuam yuav raug xa los ntawm MMA, ua raws li cov lus cog tseg thiab ntawm DHCS cov kev taw qhia.​​ 

340B Federal Drug Discount Program​​ 

63. Tsoom Fwv Teb Chaws 340B Program yog dab tsi?​​ 

Tshooj 340B ntawm Txoj Cai Pabcuam Kev Noj Qab Haus Huv Hauv Pej Xeem (Title 42 United States Code Section 256b) tsim kom muaj tsoomfwv txoj haujlwm hu ua 340B Drug Pricing Program (340B Program), uas tau tsim nyob rau xyoo 1992 tom qab tau txais kev pom zoo ntawm Medicaid Drug Rebate Program. Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv thiab Kev Pabcuam, ib lub koomhaum nyob hauv Tebchaws Meskas Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv thiab Tib Neeg, tswj hwm thiab tswj cov haujlwm los ntawm nws Lub Chaw Haujlwm Saib Xyuas Tshuaj.​​ 

The 340B Program requires drug manufacturers to offer drugs to certain hospitals and other healthcare providers (covered entities) at a greatly reduced price. By selling drugs at lower prices, participating drug manufacturers are not required to pay Medicaid drug rebates on drugs purchased through the 340B Program and provided to a Medicaid beneficiary (better known as the provision against “duplicate discounts”).​​ 

64. Leej twg siv 340B Program?​​ 

Section 340B (a) (4) of the Public Health Services Act (Title 42 United States Code Section 256b) specifies which covered entities are eligible to participate in the 340B Program. These include qualifying hospitals, federal grantees from the Health Resources and Services Administration (HRSA), the Centers for Disease Control and Prevention (CDC), the Department of Health and Human Services’ Office of Population Affairs, and the Indian Health Service. Eligible covered entities are defined in statute and include HRSA-supported health centers and lookalikes, Ryan White clinics and State AIDS Drug Assistance programs, Medicare/Medicaid Disproportionate Share Hospitals (DSH), children’s hospitals, and other safety net providers.​​ 

When registering as a covered entity with HRSA, a covered entity may choose not to dispense 340B purchased drugs to Medicaid members or to dispense 340B purchased drugs to Medicaid members. HRSA maintains a file of covered entities that indicates whether the entity dispenses 340B purchased drugs to Medicaid patients. Although covered entities can purchase 340B drugs for all eligible patients, state Medicaid programs may only collect rebates on drugs purchased outside of the 340B Program. Additional details are available on HRSA’s 340B Drug Pricing Program website.​​ 

65. Dab tsi yog qhov kev sib cuam tshuam ntawm peb daim ntawv thov tshuaj noj thiab 340B Program?​​ 

Drugs purchased under 340B pricing and dispensed to Medicaid enrollees are excluded from both federal and state rebate collection. This exclusion prevents drug manufacturers from providing duplicate discounts on drugs purchased through the 340B Program.​​ 

Thaum Lub Kaum Hli 2009, California tau tshaj tawm txoj cai uas twb muaj lawm uas xav kom 340B cov koom haum them nyiaj tsuas yog xa 340B cov khoom muag rau Medi-Cal cov tswv cuab, thiab sau nqi ntawm lawv Cov Nqi Tshaj Lij Tshaj Lij (AAC) rau cov tshuaj no thaum xa tawm los ntawm Medi-Cal tus nqi-rau-kev pabcuam kev xa khoom, raws li Txoj Cai Lij Choj & Kev Pabcuam Kev Noj Qab Haus Huv (CodeW thiab Welfare). 14105.46 ib. 340B qhov yuav tsum tau txais cov nqi them nqi tiag tiag tsuas yog siv rau tus nqi-rau-kev pabcuam xa khoom.​​ 

Hauv txoj kev tswj xyuas kev noj qab haus huv, 340B cov tshuaj uas muab rau cov tswv cuab Medi-Cal tsis raug raws li Medi-Cal tus nqi-rau-kev pabcuam-cov nqi them nqi. Qhov no tso cai rau cov koom haum tau txais kev pab thiab Medi-Cal Managed Care Plans (MCPs) thiab/los yog Cov Kws Pab Tswv Yim Kho Mob (PBMs) sib tham sib tham txog kev them nyiaj rov qab uas ua rau cov nyiaj them rov qab ntau dua rau 340B qhov chaw nyob hauv lub chaw tswj xyuas kev noj qab haus huv thaum piv rau cov koom haum li cas los yog yuav tau them nyiaj rov qab rau Medi-for-service system. Cov nyiaj tau los no tsis tau muab faib rau lub xeev, thiab tsis yog cov nyiaj tau los ntawm lub xeev.​​ 

Medi-Cal Rx tso cai rau kom muaj kev sib haum xeeb ntawm txoj cai thiab txhim kho kev saib xyuas ntawm kev thov rau cov tshuaj uas tau muab xa tawm thiab them nqi los ntawm 340B Program.​​ 

66. Puas yog Medi-Cal Rx txwv tsis pub tus kws kho mob txuas ntxiv mus ua ib lub koom haum 340B?​​ 

Tsis yog. Tsis tas li ntawd, qhov kev thov yuav tsis hloov lossis tshem tawm 340B Program hauv California.​​ 

67. Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS hais li cas txog cov kev txhawj xeeb uas tau tshwm sim los ntawm Medi-Cal Rx rau kev tswj hwm ntawm 340B Program?​​ 

DHCS lees paub lub luag haujlwm tseem ceeb ntawm peb cov chaw muab kev nyab xeeb thiab cov haujlwm tseem ceeb uas lawv ua rau cov neeg tau txais txiaj ntsig Medi-Cal. DHCS tau ua haujlwm thiab txuas ntxiv ua haujlwm sib koom tes thiab koom nrog kev sib tham nrog ntau tus neeg txaus siab thiab cov neeg koom nrog sawv cev ntawm cov chaw kho mob thiab pab pawg kom nkag siab zoo txog qhov cuam tshuam ntawm kev siv Medi-Cal Rx ntawm lawv qhov Kev Pabcuam 340B thiab lwm yam txheej txheem, nrog rau kev sib tham ntxiv txog cov kev xaiv rau kev txo qis.​​ 

68. DHCS yuav faib li cas thiab/los yog ua kom muaj cov nyiaj pab ntxiv rau cov tsev kho mob 340B uas tsis yog tsev kho mob?​​ 

DHCS tau hu ib pab pawg neeg koom tes los tsim cov txheej txheem rau kev faib cov nyiaj pab ntxiv rau cov tsev kho mob tsis yog tsev kho mob 340B hauv zej zog. Cov ntsiab lus ntawm pawg neeg ua haujlwm suav nrog cov qauv tsim nyog tau txais kev them nyiaj ntxiv, tag nrho cov nyiaj hauv pas dej ua ke muaj nyob rau hauv ib lub xyoo nyiaj txiag, thiab cov txheej txheem rau kev faib cov nyiaj hauv pas dej ntawm cov tsev kho mob tsis tsim nyog 340B hauv zej zog nrog rau lub sijhawm, zaus, thiab cov nyiaj tau los ntawm cov nyiaj tau los ntxiv. Lub Xeev Txoj Kev Hloov Kho (SPA) tau pom zoo. Tsis tas li ntawd, tsab ntawv ceeb toom tau tshaj tawm thaum Lub Rau Hli 28, 2023, hais tias DHCS yuav them nyiaj ntxiv rau qhov tsim nyog tsis yog tsev kho mob 340B cov chaw kho mob hauv zej zog rau hnub ua haujlwm txij Lub Xya Hli 1, 2023 txog Lub Kaum Ob Hlis 31, 2023, raws li cov cai ntawm Assembly Bill 80.​​ 

Medi-Cal Rx Kev Tsis Txaus Siab / Kev Tsis Txaus Siab Kev daws teeb meem & Cov txheej txheem thov rov hais dua​​ 

69. Cov txheej txheem daws teeb meem kev tsis txaus siab thiab kev tsis txaus siab dab tsi yuav Medi-Cal cov neeg tau txais txiaj ntsig yuav tsum tau daws cov teeb meem nyiaj pab hauv khw muag tshuaj?​​ 

In partnership with MMA, DHCS is committed to implementing and overseeing an effective Medi-Cal Rx complaint and grievances process to ensure appropriate triaging, referral, and/or disposition. Specific requirements are outlined in Request for Proposal #19-96125, Exhibit A, Attachment II – Scope of Work Operations – Complaints and Grievances Resolution. In addition, DHCS’ Medi-Cal Rx Complaints and Grievances Policy is posted on DHCS’ Med-Cal Rx Transition webpage.​​ 

70. Cov kev tsis txaus siab thiab kev tsis txaus siab ntawm lub tsev muag tshuaj twg yuav raug daws los ntawm Medi-Cal Rx?​​ 

All pharmacy-related complaints and grievances for Medi-Cal Rx services provided after the Medi-Cal Rx full Assumption of Operations on January 1, 2022, will be handled through Medi‑Cal Rx’s Customer Service Center for triaging, research, and resolution. For more information, please see DHCS’ Medi-Cal Rx Complaints and Grievances Policy.​​ 

71. Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS) tau hais li cas txog cov kev tsis txaus siab thiab kev tsis txaus siab uas tshwm sim rau cov kev pabcuam hauv chaw muag tshuaj uas muab los ntawm Medi-Cal Managed Care Plans (MCPs) rau lossis ua ntej Medi-Cal Rx tag nrho Assumption of Operations (AOO)?​​ 

Pharmacy-related complaints and grievances for services rendered or requested on or before Medi-Cal Rx full AOO on January 1, 2022, by a Medi-Cal MCP, which are for services the MCP was at risk for, must be fully adjudicated by the Medi-Cal MCP in accordance with DHCS’ All Plan Letter 17-006 and any subsequent versions.​​ 

Cov kev tsis txaus siab thiab kev tsis txaus siab ntawm cov chaw muag tshuaj tau txais tom qab Medi-Cal Rx tag nrho AOO los ntawm Medi-Cal Rx Lub Chaw Pabcuam Cov Neeg Siv Khoom (CSC) rau cov kev pabcuam los ntawm Medi-Cal MCP rau lossis ua ntej Medi-Cal Rx tag nrho AOO yuav raug xa los ntawm Medi-Cal Rx CSC mus rau Medi-Cal MCP kom tsim nyog.​​ 

Medi-Cal Rx CSC yuav qhia rau Medi-Cal MCP cov tswv cuab tias lawv yuav tsum hu rau lawv MCP rau cov kev tsis txaus siab thiab kev tsis txaus siab ntawm lub tsev muag tshuaj.​​ 

Txoj cai ntawm Medi-Cal MCP cov tswv cuab xa cov lus tsis txaus siab thiab kev tsis txaus siab rau lawv Medi-Cal MCPs rau cov kev pab cuam hauv khw muag tshuaj uas tau muab rau lossis ua ntej Medi-Cal Rx tag nrho AOO tsis cuam tshuam los ntawm Medi-Cal Rx.​​ 

72. Does Medi-Cal Rx have a mechanism to share information about complaints and grievances with the beneficiary’s Managed Care Plan (MCP)?​​ 

Medi-Cal MCPs will have complete access to individual records of beneficiaries enrolled in their plan via the Medi-Cal Rx Web Portal, including documentation of complaints and grievances. This information can be reviewed by the plan case manager on a case-by-case basis as needed. Further, relative to complaints and grievances external reporting, DHCS is exploring options and will leverage existing modalities relative to sharing this information publicly through various avenues such as DHCS’ website and Open Data Portal.​​ 

73. Cov txheej txheem thov rov hais dua li cas cov neeg tau txais txiaj ntsig Medi-Cal yuav tau daws cov teeb meem kev pab kho mob?​​ 

Appeals go through the State Fair Hearing process, which is administered through the California Department of Social Services. If Medi-Cal beneficiaries do not agree with a denial or change of Medi-Cal Rx services, they can ask for a State Fair Hearing. Fair Hearings can be requested online or by phone, fax, mail, or email. For more information about the State Hearing process, refer to the Notice of Action (NOA) that you received or visit DHCS’ Medi-Cal Fair Hearing website or the California Department of Social Services’ website. Medi-Cal beneficiaries may also call to ask for a State Fair Hearing toll-free at 1-800-952-5253 (TTY 1-800-952-8349). Please note that the number can be very busy so you may get a message to call back later.​​ 

74. Yog tias tus neeg tau txais txiaj ntsig Medi-Cal xav tau Lub Xeev Lub Rooj Sib Hais Ncaj Ncees, puas muaj sijhawm txwv?​​ 

Yog lawm, cov neeg tau txais txiaj ntsig Medi-Cal tsuas muaj 90 hnub los thov kom muaj lub rooj sib hais, ua raws li txoj cai hauv lub xeev.​​ 

75. Cov neeg tau txais txiaj ntsig Medi-Cal puas tseem tuaj yeem tau txais lawv cov kev kho mob thaum tseem tos lub Xeev Qhov Kev Txiav Txim Siab Ncaj Ncees?​​ 

Yog lawm. Txhawm rau txuas ntxiv tau txais Medi-Cal Rx cov kev pab cuam uas daim ntawv ceeb toom tsis lees yuav tsum nres thiab/lossis hloov, Medi-Cal cov neeg tau txais txiaj ntsig yuav tsum thov kom muaj Lub Rooj Sib Hais Hauv Lub Xeev tsis pub dhau kaum hnub txij hnub NOA, lossis ua ntej hnub, tsab ntawv ceeb toom hais tias koj qhov kev kho mob yuav nres lossis hloov, qhov twg yog tom qab.​​ 

Thaum thov Lub Xeev Lub Rooj Sib Hais Ncaj Ncees, Medi-Cal cov neeg tau txais txiaj ntsig yuav tsum tau qhia tias lawv xav kom tau txais Medi-Cal Rx cov kev pab cuam thaum lub rooj sib hais. Thov nco ntsoov tias nws tuaj yeem siv sijhawm ntev txog 90 hnub rau qhov kev txiav txim siab thiab qhov kev txiav txim zaum kawg raug xa mus rau tus neeg txais txiaj ntsig Medi-Cal.​​ 

76. Cov neeg tau txais txiaj ntsig Medi-Cal puas tuaj yeem thov kom muaj lub Rooj Sib Hais Ncaj Ncees hauv Xeev?​​ 

Yog lawm. Cov neeg tau txais txiaj ntsig Medi-Cal tuaj yeem thov kom muaj lub rooj sib hais nrawm los ntawm kev xa tsab ntawv los ntawm lawv tus kws kho mob piav qhia tias tos txog li 90 hnub tuaj yeem pheej hmoo rau lawv lub neej thiab / lossis kev noj qab haus huv. Cov neeg tau txais txiaj ntsig Medi-Cal yuav tsum xa tsab ntawv nrog rau lawv qhov kev thov rooj sib hais. Yog xav paub ntxiv txog cov txheej txheem Rooj Hais Plaub Hauv Xeev, thov mus saib hauv DHCS' Medi-Cal Fair Hearing lub website.​​ 

77. Rau kev thov rov hais dua ntawm Medi-Cal Rx qhov kev txiav txim siab los ntawm Medi-Cal tus kws kho mob thiab/lossis Managed Care Plan (MCP), DHCS puas yuav tsim ib qho txheej txheem rov hais dua Medi-Cal Rx sab nraud uas cov kws kho mob ywj pheej tshuaj xyuas cov kev txiav txim?​​ 

No, at this time, DHCS is not exploring creating a separate independent medical review process, akin to that currently overseen by the California Department of Managed Health Care, for Medi-Cal Rx. As a reminder, Medi-Cal Rx denials for pharmacy claims will not be made by Medi-Cal providers and/or MCPs; rather, they will initially be made by MMA and reviewed by DHCS for final determination. As mentioned elsewhere in this document, Medi-Cal providers can appeal Medi-Cal Rx denials consistent with the requirements outlined in Request for Proposal #19-96125, Exhibit A, Attachment II – Scope of Work Operations – Claims Administration, applicable state law requirements, and DHCS’ policies/procedures.​​ 

78. Qhov kev thov rov hais dua txog tsev muag tshuaj dab tsi yuav raug daws los ntawm Medi-Cal Rx?​​ 

Txhua qhov kev thov rov hais dua txog lub tsev muag tshuaj rau Medi-Cal Rx cov kev pabcuam uas tau muab tom qab Medi-Cal Rx tag nrho Kev Pom Zoo ntawm Kev Ua Haujlwm yuav raug tswj xyuas los ntawm Medi-Cal Rx siv cov txheej txheem Kev Ncaj Ncees Hauv Xeev uas twb muaj lawm, tswj hwm los ntawm California Department of Social Services, raws li tau piav qhia hauv nqe lus nug #73-76 saum toj no.​​ 

79. Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS) tau hais li cas txog kev thov rov hais dua los ntawm Medi-Cal Managed Care Plan (MCP) cov neeg tau txais txiaj ntsig uas tau tshwm sim rau cov kev pab cuam hauv khw muag tshuaj uas muab los ntawm Medi-Cal MCPs rau lossis ua ntej Medi-Cal Rx tag nrho Assumption of Operations (AOO)?​​ 

Medi-Cal MCPs yuav tsum daws tag nrho Medi-Cal MCP cov neeg tau txais kev thov rov hais dua uas tau tshwm sim los ntawm qhov kev txiav txim siab MCP cuam tshuam rau cov kev pab cuam hauv khw muag tshuaj uas MCP muaj kev pheej hmoo rau los yog ua ntej Medi-Cal Rx puv AOO. Txoj cai ntawm Medi-Cal MCP cov tswvcuab xa daim ntawv thov rov hais dua mus rau Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv, suav nrog tab sis tsis txwv rau txoj cai rau Independent Medical Review, rau cov kev pab cuam hauv khw muag tshuaj uas muab los ntawm Medi-Cal MCPs ua ntej lossis ua ntej Medi-Cal Rx tag nrho AOO, tsis cuam tshuam los ntawm Medi-Cal Rx.​​ 

Kev cuam tshuam txog nyiaj txiag / kev soj ntsuam​​ 

80. Did the Department of Health Care Services (DHCS) complete a fiscal analysis prior to the transition?​​ 

Yog lawm. DHCS tau ua tiav qhov kev txheeb xyuas nyiaj txiag rau Medi-Cal Rx thiab qhia cov ntaub ntawv no rau pej xeem. DHCS kwv yees kwv yees li $ 309 lab Nyiaj Txiag (GF) hauv kev khaws nyiaj txhua xyoo los ntawm 2023-24. DHCS suav nrog kev kwv yees nyiaj txiag rau Medi-Cal Rx uas yog ib feem ntawm cov txheej txheem Medi-Cal kwv yees ob xyoos ib zaug, thiab yuav muab cov kev hloov kho uas tsim nyog, yog tias muaj, rau kev txheeb xyuas nyiaj txiag raws li kev mus tom ntej.​​ 

81. Dab tsi yog cov ntsiab lus ntawm peb qhov phiaj xwm $ 309 lab General Fund (GF) hauv kev khaws nyiaj txhua xyoo los ntawm 2023-24?​​ 

Cov ntsiab lus ntawm kev kwv yees $ 309 lab GF khaws cia los ntawm 2023-24 suav nrog tab sis tsis txwv rau cov hauv qab no:​​ 

• Lub xeev ntxiv cov tshuaj ntxiv nyiaj rov qab los ntawm kev hloov pauv ntawm kev siv tshuaj los ntawm kev tswj hwm kev saib xyuas mus rau tus nqi-rau-kev pabcuam.​​ 
• Kev Siv Cov Nqi Tshaj Lij Tshaj Lij Tshaj Lij Tshaj Lij Tshaj Lij (MAICs) rau cov tshuaj uas muaj peb (3) lossis ntau dua cov kev xaiv sib npaug.​​ 
• Txo cov nqi cuam tshuam txog kev tswj hwm ntawm ntau lub chaw muag tshuaj cov nyiaj pab tswj xyuas siv los ntawm ntau yam Medi-Cal Managed Care Plans (MCPs).​​ 
• Medi-Cal tus nqi-rau-kev pabcuam them rov qab, uas suav nrog $10.05/$13.20 tus nqi xa khoom.​​ 
• Ib qho kev them nyiaj ntxiv tshiab rau cov tsev kho mob 340B uas tsis yog tsev kho mob, tau txais txiaj ntsig nrog Medi-Cal Rx tag nrho Assumption of Operations nyob rau lub Ib Hlis 1, 2022, tau suav nrog hauv 2021-22 pob nyiaj siv. Saib nqe lus nug #70 saum toj no yog xav paub ntxiv.​​ 

Raws li tau sau tseg hauv nqe lus nug #80 saum toj no, txhua qhov kev hloov kho rau Medi-Cal Rx kev kwv yees nyiaj txiag, suav nrog kev kwv yees nyiaj khaws cia, yuav raug hloov kho raws li ib feem ntawm cov txheej txheem Medi-Cal kwv yees ob xyoos.​​ 

Lwm yam / Lwm Cov Ntaub Ntawv​​ 

82. Puas yog Medi-Cal Rx suav nrog kev xaiv chaw muag tshuaj?​​ 

Yog lawm. Cov kev xaiv xa ntawv muaj nyob hauv Medi-Cal los ntawm Medi-Cal Rx. Yog hais tias lub tsev muag tshuaj yog ib lub chaw muab tshuaj Medi-Cal rau npe, lub tsev muag tshuaj yuav muab tshuaj rau ntawm qhov chaw lossis los ntawm kev xa ntawv xaj. Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS) tau ua kom muaj kev xaiv kev xa ntawv xa mus tau zoo rau Medi-Cal cov chaw muag tshuaj.​​ 

83. Puas yog Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS) puas ua rau Medi-Cal cov chaw muag tshuaj ntxiv cov ntawv cog lus rov qab rau pej xeem?​​ 

Tsis yog. Ob lub xeev thiab tseemfwv txoj cai lij choj tiv thaiv kev tsis pub lwm tus paub ntawm cov ntawv cog lus them rov qab tshuaj ntxiv.​​ 

84. Puas yog Medi-Cal Rx Tus Neeg Ua Haujlwm yuav tsum tau cog lus nrog cov khw muag tshuaj uas twb muaj lawm hauv cov tes hauj lwm tam sim no?​​ 

Tsis yog. Magellan Medicaid Administration, LLC (MMA) tsis tau cog lus nrog ib tus kws kho mob. Tag nrho cov kev ua ub no ntawm tus kws kho mob thiab kev saib xyuas ntawm Medi-Cal lub chaw muag tshuaj yog khaws cia los ntawm Lub Tsev Haujlwm Saib Xyuas Kev Kho Mob (DHCS).​​ 

84. Muaj pes tsawg lub khw muag tshuaj uas muaj ntawv tso cai hauv California tau tso npe rau hauv Medi-Cal tus nqi-rau-kev pabcuam?​​ 

Nyob rau lub Ib Hlis Ntuj xyoo 2023, Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS) cov ntaub ntawv, 6,547 California cov chaw muag tshuaj muaj ntawv tso cai tau tso npe rau hauv Medi-Cal tus nqi-rau-kev pabcuam.​​ 

85. Puas yog Medi-Cal koom nrog rau kev rau npe rau cov khw muag tshuaj uas yog ib feem ntawm Managed Care Plan (MCP) tes hauj lwm tab sis tsis sau npe hauv Medi-Cal tus nqi-rau-kev pabcuam?​​ 

Since Medi-Cal Rx’s full Assumption of Operations (AOO) on January 1, 2022, Medi-Cal Rx uses Medi-Cal’s extensive statewide network of pharmacies that are enrolled as Medi-Cal providers. Medi-Cal enrolled pharmacies account for the vast majority of all California-licensed pharmacies. Medi-Cal MCPs currently use these same pharmacies as well as some additional pharmacies not yet enrolled as Medi-Cal pharmacy providers. The Department of Health Care Services (DHCS) has analyzed the MCP pharmacy networks, identified potential gaps where pharmacies are providing services in managed care but are not enrolled in fee-for-service, and has sent notices to those pharmacies reminding them they must enroll as a Medi-Cal pharmacy provider to continue to serve the Medi-Cal population through Medi-Cal Rx as of full AOO.​​ 

86. Yuav muaj peev xwm npaum li cas Medi-Cal Managed Care Plans (MCPs) thiab lwm lub koom haum yuav tsum koom nrog hauv cov rooj sib tham rau Medi-Cal Ntiaj Teb Kev Siv Tshuaj Ntsuam Xyuas (DUR) thiab lwm Lub Tsev Haujlwm Saib Xyuas Kev Kho Mob (DHCS) pawg kws muag tshuaj?​​ 

Tam sim no thiab tsis tu ncua tom qab kev hloov pauv, DHCS cia siab tias nws cov Medi-Cal MCPs thiab lwm tus neeg txaus siab yuav koom nrog cov rooj sib tham uas cuam tshuam nrog Medi-Cal Global DUR Board thiab hauv lwm pawg kws muag tshuaj DHCS, raws li xav tau. Tsis tas li ntawd, DHCS tseem niaj hnub soj ntsuam thiab tshuaj xyuas seb yuav ua li cas thiaj li muaj txiaj ntsig zoo thiab koom tes nrog Medi-Cal MCPs thiab lwm lub koom haum hauv kev sib tham thiab kev txiav txim siab ntsig txog Medi-Cal txoj cai mus rau tom khw muag tshuaj.​​ 

87. Puas yog Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS) puas muaj kev pabcuam rau kev hloov kho thiab xov xwm ntsig txog Medi-Cal Rx?​​ 

Yes, it is called the Medi-Cal Rx Subscription Service (MCRxSS). All interested parties are encouraged to sign up for MCRxSS to receive news and updates related to Medi-Cal Rx.​​