Tsev Cov Chaw Muab Kev Pabcuam & Cov Neeg Koom Tes Kev Pab Cuam Txog Kev Muag Tshuaj thiab Kev Pab Cuam Saib Xyuas Qhov Muag Kev Pab Cuam Txog Medi-Cal

Medi-Cal Rx

Txheej txheem cej luam

On January 7, 2019, Governor Gavin Newsom issued Executive Order N-01-19 to achieve cost-savings for drug purchases made by the state. A key component of the order requires the DHCS to transition all Medi-Cal pharmacy services from managed care (MC) to fee-for-service (FFS).

Kev hloov chaw muag tshuaj los ntawm MC mus rau FFS yuav, nrog rau 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 Medi-Cal beneficiary access to pharmacy services with a pharmacy network that includes approximately 94% of the state’s pharmacies.

These Medi-Cal pharmacy benefits and services administered by DHCS in the FFS delivery system will be identified collectively as “Medi-Cal Rx”.

Lwm yam kev hloov pauv uas tshwm sim los ntawm kev hloov mus rau FFS suav nrog:

Siv cov kev tswj xyuas kev siv thoob plaws hauv xeev rau txhua yam tshuaj kho mob sab nraud.
Strengthen California’s ability to negotiate state supplemental drug rebates with drug manufacturers.

Cov ntaub ntawv thiab cov ntaub ntawv siv

Cov hauv qab no yog cov peev txheej thiab cov ntaub ntawv siv rau cov neeg tau txais txiaj ntsig thiab cov neeg muab kev pabcuam hais txog Medi-Cal Rx cov kev pabcuam:

Medi-Cal Rx Claim Edits and Prior Authorization Reinstatement Plan: This is a phased approach for the reinstatement of claim edits and prior authorizations, and the phasing out of the Transition Policy. The June 2022 Medi-Cal Rx Reinstatement of Prior Authorizations and Retirement of the Transition Policy Phase I presentation, and the December 2022 Phases II, III, and IV presentation. The September 2023 Advancing Medi-Cal Rx presentation. For more information on the Medi-Cal RX Reinstatement, you can go to the Medi-Cal Rx Portal/ Education and Outreach Webpage.
Medi-Cal Rx Conflict Avoidance Plan: Updated August 29, 2022. On July 27, 2021, DHCS accepted a Conflict Avoidance Plan submitted by its Medi-Cal Rx vendor, MMA, a subsidiary of Magellan Health, Inc. (Magellan), to mitigate conflicts associated with the proposed acquisition of Magellan by Centene Corporation.
Medi-Cal Rx Website: Starting on January 1, 2021, the new Medi-Cal Rx site will be the place to go to access both public and secure Medi-Cal Rx portals. Starting on January 1, 2022, the secure portal will give pharmacy providers, prescribers and their staff access to the Prior Authorization (PA) system; beneficiary drug look-up tool; and web and batch claims submissions.
Medi-Cal Rx Frequently Asked Questions (FAQs): Updated April 18, 2023, this document provides additional guidance and clarification to Medi-Cal beneficiaries, providers, plan partners, and other interested parties on COVID-19 over the counter (OTC) Self-Administered Antigen Tests. As DHCS receives additional questions, this document will be updated as indicated by the version number and date in the footer.
Medi-Cal Rx Pharmacy Transition Policy: Updated April 7, 2021, this document describes DHCS’ multi-faceted pharmacy transition policy, inclusive of “grandfathering” previously approved PAs from managed care and fee-for-service, as well as a 180-day period with no PA requirements for existing prescriptions, that helped in supporting Medi-Cal Rx transition. During this transition period, Magellan provided system messaging, reporting and outreach to grant Medi-Cal Rx a smooth transition.
Medi-Cal Rx PA/Utilization Management (UM) and Related Appeals Processes: Updated November 05, 2021 this document outlines DHCS’ FFS Medi-Cal PA/UM and related appeals processes, which align with and build upon existing Medi-Cal FFS processes and protocols for the Medi-Cal program more broadly. This update reflects the new Medi-Cal Rx implementation date and contains a revised Medi-Cal Fair Hearing stakeholder engagement timeline.
Medi-Cal Rx Complaints and Grievances: Updated April 7, 2021, this document outlines DHCS’ FFS Medi-Cal Rx complaints and grievances policy, which aligns with and builds upon existing Medi-Cal FFS processes and protocols for the Medi-Cal program, more broadly.
Medi-Cal Rx Website & Pharmacy Portal Policy:Updated July 19, 2023, this document offers information about DHCS’ dedicated Medi-Cal Rx website, which is now live and offers content available on a public platform that is accessible by all. Additionally, the Medi-Cal Rx website launched several different secure portals for the beneficiaries, providers (including physician prescribers and pharmacies), managed care plan (MCP) partners, and other entities as determined by DHCS, to ensure their access to the appropriate tools and resources for Medi-Cal Rx services that require access to protected health information.
Medi-Cal Rx MCP Clinical Liaison Policy: Updated April 7, 2021, this document describes how Medi-Cal Rx will provide a dedicated Clinical Liaison (CL) team to support the Medi-Cal MCPs in their clinical obligations relating to beneficiary care coordination, medication adherence, and other responsibilities related to medication requirements. The Medi-Cal MCPs will be provided access to the MCP CL’s through Medi-Cal Rx’s dedicated Integrated Voice Response system to assist and resolve clinical pharmacy-related issues, as outlined in this document.
Medi-Cal Rx Scope: Updated October 1, 2024, this document provides additional context and information related to the Department’s implementation of the Medi-Cal MC to FFS pharmacy carve out, effective January 1, 2022. It also provides an inventory of the Medi-Cal pharmacy benefit, characterized as either not subject to the carve out (i.e., those pharmacy benefits that are billed on medical and institutional claims), versus those subject to the carve out (i.e., all pharmacy benefits that are billed on pharmacy claims).

Stakeholder Engagement

Raws li ib feem ntawm qhov kev hloov pauv no, DHCS tau cog lus los ua haujlwm nrog nws cov neeg koom nrog sab nraud (xws li tab sis tsis txwv rau, MCP, Lub Nroog, Cov Chaw Pabcuam, Cov Neeg Siv Khoom, thiab cov neeg tau txais txiaj ntsig) kom ntseeg tau tias muaj kev hloov pauv thiab ua tiav los ntawm cov hauv qab no:

Tshaj tawm tshaj tawm cov ntaub ntawv qhia tawm (xws li Daim Ntawv Thov Kev Pom Zoo, cov chaw muab kev pabcuam thiab cov ntawv ceeb toom tau txais txiaj ntsig, Txhua Daim Ntawv Npaj, thiab lwm yam) rau kev tawm tswv yim.
Ua kom MCPs, Lub Nroog, cov chaw muab kev pabcuam, cov neeg txhawb nqa cov neeg siv khoom, thiab cov neeg tau txais txiaj ntsig tau txais cov ntaub ntawv raug raws sijhawm thiab raug hais txog kev hloov pauv thiab cov haujlwm cuam tshuam nrog.
Muab cov xwm txheej hloov kho tshiab thiab sib sau cov lus tawm tswv yim los ntawm cov neeg koom nrog ntau yam DHCS-sponsored public conferences.

Nco tseg: Ntxiv nrog rau cov rooj sib tham nyob ib leeg, DHCS yuav tab tom nrhiav kom txhawb nqa cov rooj sib tham thiab pab pawg ua haujlwm (xws li Pawg neeg saib xyuas cov neeg koom nrog, pawg neeg saib xyuas cov neeg siv khoom sib koom ua haujlwm, Medi-Cal Tus Thawj Saib Xyuas Kev Kho Mob cov rooj sib tham) los muab cov xwm txheej hloov tshiab ntawm kev siv zog thiab cov dej num ntsig txog Medi-Cal Rx.

Rau cov tib neeg uas muaj kev tsis taus, Lub Tsev Haujlwm yuav muab cov cuab yeej pab xws li kev txhais lus kos npe, sau npe hauv lub sijhawm, cov neeg sau ntawv, kev nyeem ntawv lossis kev sau ntawv thiab hloov cov kev qhia lossis cov ntaub ntawv sib tham rau hauv Braille, luam ntawv loj, audiocassette, lossis computer disk. Txhawm rau thov cov kev pabcuam lossis cov ntawv luam ua lwm hom, thov hu lossis sau ntawv:

Lori Bradley, RPh
Department of Health Care Services
Pharmacy Benefits Division, MS 4604
Sacramento, CA 95814
Phone Number: (916) 552-9500
Email: medi-cal.pharmacybenefits@dhcs.ca.gov

Thov nco ntsoov, qhov ntau ntawm cov kev pab cuam muaj peev xwm yuav raug txwv yog tias kev thov tau txais tsawg dua kaum hnub ua haujlwm ua ntej lub rooj sib tham lossis kev tshwm sim.

Medi-Cal Rx Advisory Workg roup

The Medi-Cal Rx Advisory Workgroup will meet three times between August 2021 and January 1, 2022 Assumption of Operations to help facilitate and further inform DHCS’ ongoing Medi-Cal Rx implementation efforts. Each Medi-Cal Rx Advisory Workgroup meeting will be held in Sacramento for approximately four hours. The Medi-Cal Rx Advisory Workgroup membership will be limited to 30 members to ensure a productive discussion environment. The Medi-Cal Rx Advisory Workgroup to be comprised of organizations and entities such as hospitals, clinics, health plans, counties, pharmacies, tribal health programs, consumer advocates and others. During the meetings, DHCS will provide updates on the pharmacy transition and request the Medi-Cal Rx Advisory Workgroup provide dialogue and input key topics, such as:

Lub luag haujlwm thiab lub luag haujlwm ntawm DHCS, Medi-Cal Rx Tus Neeg Ua Haujlwm, thiab Medi-Cal Kev Npaj Kho Mob
DHCS’ implementation strategies, tools, and timelines, including but not limited to, provider education and outreach and beneficiary notifications
Medi-Cal txoj cai txhim kho lub tsev muag tshuaj, uas yuav suav nrog qhov kev nthuav tawm, kev tso cai ua ntej, thiab cov txheej txheem tswj kev siv
Kev hloov pauv rau pawg kws muag tshuaj Medi-Cal uas twb muaj lawm

Tom qab kev hloov pauv, Medi-Cal Rx Advisory Workgroup cov rooj sib tham yuav tsom mus rau kev sau cov ntaub ntawv, cov kev paub dhau los thiab / lossis cov lus tawm tswv yim los ntawm pawg neeg ua haujlwm los pab kho cov txheej txheem Medi-Cal Rx thiab cov cai tsis tu ncua. Cov rooj sib tham yuav qhib rau pej xeem, thiab cov lus tawm tswv yim ntawm tus kheej yuav raug lees txais rau 30 feeb kawg ntawm txhua lub rooj sib tham. Cov ntsiab lus ntxiv, suav nrog tab sis tsis txwv rau kev txheeb xyuas thiab chaw nres tsheb cov ntaub ntawv, yuav raug tshaj tawm nrog cov txheej txheem tsawg kawg 10 hnub ua ntej txhua lub rooj sib tham.

Medi-Cal Rx Advisory Workgroup Sau Npe

Medi-Cal Rx Advisory Workgroup teem caij ntsib

Medi-Cal Rx Public Forum

Pib txij Lub Xya Hli 2019 thiab txuas ntxiv mus thoob plaws xyoo 2020, DHCS tau tuav thiab tseem yuav tuav ib (1) teev Medi-Cal Rx Public Forums ntawm tus kheej thiab hauv webinar los muab cov xwm txheej hloov tshiab los pab xyuas kom cov neeg muaj feem cuam tshuam nrog lub zej zog. tshiab txog kev siv Medi-Cal Rx cov dej num thiab ncua sij hawm. Txhua lub rooj sib tham Medi-Cal Rx Public Forum cov hnub thiab sijhawm muaj nyob hauv qab no. Txhua lub koom haum thiab cov koom haum txaus siab, suav nrog tab sis tsis txwv rau, tsev kho mob, chaw kho mob, cov phiaj xwm kev noj qab haus huv, nroog, khw muag tshuaj, pab pawg neeg noj qab haus huv, thiab cov neeg tawm tswv yim, raug caw tuaj koom.

Medi-Cal Rx Lub Rooj Sib Tham Pej Xeem

DHCS yuav tshaj tawm cov ntaub ntawv ntxiv nrog rau cov ntawv ceeb toom ceeb toom los ntawm ntau DHCS cov koom nrog cov npe xa email. Ntxiv rau, DHCS tseem yuav tshaj tawm cov txheej txheem zaum kawg tsawg kawg 10 hnub ua ntej txhua lub rooj sib tham.

Medi-Cal Rx: Archives

All archived material from this page.

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For general questions relating to Medi-Cal Rx, please direct your comments and questions to medi-cal.pharmacybenefits@dhcs.ca.gov.

Medi-Cal Rx​​

Txheej txheem cej luam​​

Cov ntaub ntawv thiab cov ntaub ntawv siv​​

Stakeholder Engagement​​

Medi-Cal Rx Advisory Workg roup​​

Medi-Cal Rx Advisory Workgroup teem caij ntsib​​

Medi-Cal Rx Public Forum​​

Medi-Cal Rx Lub Rooj Sib Tham Pej Xeem​​

Medi-Cal Rx: Archives​​

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