ບ້ານ ຜູ້ໃຫ້ບໍລິການ ແລະ ຄູ່ຮ່ວມງານ ພະແນກຜົນປະໂຫຍດດ້ານຮ້ານຂາຍຢາ ແລະ ໂຄງການດູແລສາຍຕາ ແພດປິ່ນປົວ Medi-Cal

Medi-Cal Rx

ພາບລວມ

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).

ການຫັນປ່ຽນການບໍລິການຮ້ານຂາຍຢາຈາກ MC ເປັນ FFS ຈະ, ໃນບັນດາສິ່ງອື່ນໆ:

ສ້າງມາດຕະຖານຜົນປະໂຫຍດຂອງຮ້ານຂາຍຢາ Medi-Cal ໃນທົ່ວລັດ, ພາຍໃຕ້ລະບົບການຈັດສົ່ງດຽວ.
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”.

ການປ່ຽນແປງອື່ນໆທີ່ເປັນຜົນມາຈາກການຫັນເປັນ FFS ປະກອບມີ:

ນຳໃຊ້ໂປຣໂຕຄອນການຈັດການການນຳໃຊ້ທົ່ວລັດກັບທຸກຢາຄົນເຈັບນອກ.
Strengthen California’s ability to negotiate state supplemental drug rebates with drug manufacturers.

ຊັບພະຍາກອນແລະເອກະສານອ້າງອີງ

ຕໍ່ໄປນີ້ແມ່ນຊັບພະຍາກອນ ແລະເອກະສານອ້າງອີງສຳລັບຜູ້ໄດ້ຮັບຜົນປະໂຫຍດ ແລະຜູ້ໃຫ້ບໍລິການກ່ຽວກັບການບໍລິການ Medi-Cal Rx:

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).

ການມີສ່ວນພົວພັນຂອງຜູ້ຖືຫຸ້ນ

ເປັນສ່ວນຫນຶ່ງຂອງການຫັນປ່ຽນນີ້, DHCS ມຸ່ງຫມັ້ນທີ່ຈະເຮັດວຽກກັບຄູ່ຮ່ວມງານພາຍນອກຂອງຕົນ (ລວມທັງແຕ່ບໍ່ຈໍາກັດ, MCP, ເຂດປົກຄອງ, ຜູ້ໃຫ້ບໍລິການ, ຜູ້ສະຫນັບສະຫນູນຜູ້ບໍລິໂພກ, ແລະຜູ້ໄດ້ຮັບຜົນປະໂຫຍດ) ເພື່ອຮັບປະກັນການຫັນປ່ຽນທີ່ລຽບແລະປະສົບຜົນສໍາເລັດໂດຍຜ່ານສິ່ງຕໍ່ໄປນີ້:

ເຜີຍແຜ່ເອກະສານແຈ້ງການສະບັບຮ່າງ (ເຊັ່ນຄຳຮ້ອງສະເໜີ, ແຈ້ງການຜູ້ໃຫ້ບໍລິການ ແລະ ຜູ້ຮັບຜົນປະໂຫຍດ, ຈົດໝາຍແຜນການທັງໝົດ, ແລະ ອື່ນໆ) ເພື່ອໃຫ້ຄຳເຫັນ.
ຮັບປະກັນ MCPs, ເຂດປົກຄອງ, ຜູ້ໃຫ້ບໍລິການ, ຜູ້ສະຫນັບສະຫນູນຜູ້ບໍລິໂພກ, ແລະຜູ້ໄດ້ຮັບຜົນປະໂຫຍດໄດ້ຮັບຂໍ້ມູນທີ່ຖືກຕ້ອງແລະທັນເວລາທີ່ກ່ຽວຂ້ອງກັບການຫັນປ່ຽນແລະກິດຈະກໍາການປະຕິບັດທີ່ກ່ຽວຂ້ອງ.
ສະໜອງການອັບເດດສະຖານະ ແລະເກັບກຳຂໍ້ຄິດເຫັນຈາກຜູ້ມີສ່ວນກ່ຽວຂ້ອງຜ່ານກອງປະຊຸມສາທາລະນະຕ່າງໆທີ່ໄດ້ຮັບການສະໜັບສະໜູນໂດຍ DHCS.

ໝາຍເຫດ: ນອກເໜືອໄປຈາກກອງປະຊຸມແບບຢືນຢູ່ຄົນດຽວ, DHCS ຈະຊອກຫາເພື່ອນຳໃຊ້ການປະຊຸມ ແລະກຸ່ມວຽກທີ່ມີຢູ່ (ເຊັ່ນ: ຄະນະກໍາມະການທີ່ປຶກສາຜູ້ຖືສ່ວນກ່ຽວຂ້ອງ, ກຸ່ມເຮັດວຽກທີ່ສຸມໃສ່ຜູ້ມີສ່ວນຮ່ວມຂອງຜູ້ບໍລິໂພກ, ກອງປະຊຸມຜູ້ອໍານວຍການດ້ານການແພດຂອງ Medi-Cal) ເພື່ອສະຫນອງການປັບປຸງສະຖານະພາບກ່ຽວກັບຄວາມພະຍາຍາມປະຕິບັດແລະກິດຈະກໍາທີ່ກ່ຽວຂ້ອງກັບ Medi-Cal Rx.

ສໍາລັບບຸກຄົນທີ່ມີຄວາມພິການ, ກົມຈະສະຫນອງອຸປະກອນການຊ່ວຍເຫຼືອເຊັ່ນ: ການຕີຄວາມຫມາຍພາສາມື, ຄໍາອະທິບາຍແບບສົດໆ, ເຄື່ອງບັນທຶກ, ການຊ່ວຍເຫຼືອການອ່ານຫຼືການຂຽນແລະການແປງອຸປະກອນການຝຶກຫຼືການປະຊຸມເປັນ Braille, ພິມຂະຫນາດໃຫຍ່, audiocassette, ຫຼືແຜ່ນຄອມພິວເຕີ. ເພື່ອຮ້ອງຂໍການບໍລິການດັ່ງກ່າວຫຼືສໍາເນົາໃນຮູບແບບທາງເລືອກ, ກະລຸນາໂທຫາຫຼືຂຽນ:

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

ກະລຸນາຮັບຊາບ, ຂອບເຂດຂອງການບໍລິການຊ່ວຍເຫຼືອທີ່ມີຢູ່ອາດຈະຈໍາກັດຖ້າການຮ້ອງຂໍໄດ້ຮັບຫນ້ອຍກວ່າສິບມື້ເຮັດວຽກກ່ອນກອງປະຊຸມຫຼືເຫດການ.

ຄະນະທີ່ປຶກສາ Medi-Cal Rx

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:

ບົດບາດ ແລະຄວາມຮັບຜິດຊອບຂອງ DHCS, ຜູ້ຮັບເໝົາ Medi-Cal Rx, ແລະ Medi-Cal Managed Care Plans
DHCS’ implementation strategies, tools, and timelines, including but not limited to, provider education and outreach and beneficiary notifications
ການພັດທະນານະໂຍບາຍຮ້ານຂາຍຢາ Medi-Cal, ເຊິ່ງຈະລວມເອົາຂອບເຂດຂອງການຕັດອອກ, ການອະນຸຍາດກ່ອນ, ແລະອະນຸສັນຍາການຄຸ້ມຄອງການນໍາໃຊ້
ການປ່ຽນແປງຄະນະກໍາມະການຮ້ານຂາຍຢາ Medi-Cal ທີ່ມີຢູ່ແລ້ວ

ຫຼັງຈາກການປ່ຽນແປງ, ກອງປະຊຸມກຸ່ມທີ່ປຶກສາຂອງ Medi-Cal Rx ຈະເນັ້ນໃສ່ການເກັບກຳຂໍ້ມູນ, ປະສົບການ ແລະ/ຫຼື ຄຳຄິດເຫັນຈາກສະມາຊິກໃນກຸ່ມເພື່ອຊ່ວຍປັບປຸງຂະບວນການ ແລະ ນະໂຍບາຍຂອງ Medi-Cal Rx ຢ່າງຕໍ່ເນື່ອງ. ກອງປະຊຸມຈະເປີດໃຫ້ປະຊາຊົນ, ແລະຄໍາຄິດເຫັນໂດຍບຸກຄົນທີ່ສາທາລະນະຈະໄດ້ຮັບການຍອມຮັບສໍາລັບ 30 ນາທີສຸດທ້າຍຂອງການປະຊຸມ. ລາຍລະອຽດເພີ່ມເຕີມ, ລວມທັງແຕ່ບໍ່ຈໍາກັດການເຊັກອິນແລະຂໍ້ມູນບ່ອນຈອດລົດ, ຈະຖືກປະກາດໃນກອງປະຊຸມຢ່າງຫນ້ອຍ 10 ມື້ກ່ອນກອງປະຊຸມແຕ່ລະຄັ້ງ.

ລາຍຊື່ສະມາຊິກຂອງກຸ່ມທີ່ປຶກສາ Medi-Cal Rx

ຕາຕະລາງການປະຊຸມຂອງກຸ່ມທີ່ປຶກສາຂອງ Medi-Cal Rx

ເວທີປາໄສສາທາລະນະ Medi-Cal Rx

ເລີ່ມຕົ້ນໃນເດືອນກໍລະກົດ 2019 ແລະສືບຕໍ່ຕະຫຼອດປີ 2020, DHCS ໄດ້ເປັນເຈົ້າພາບ ແລະຈະສືບຕໍ່ເປັນເຈົ້າພາບໜຶ່ງ (1) ຊົ່ວໂມງ Medi-Cal Rx Public Forums ດ້ວຍຕົນເອງ ແລະຜ່ານ webinar ເພື່ອເຮັດໃຫ້ການອັບເດດສະຖານະເພື່ອຊ່ວຍຮັບປະກັນວ່າຊຸມຊົນຜູ້ມີສ່ວນຮ່ວມທີ່ກວ້າງຂວາງຈະຖືກເກັບຮັກສາໄວ້. ອັບເດດກ່ຽວກັບກິດຈະກໍາການປະຕິບັດ Medi-Cal Rx ແລະໄລຍະເວລາ. ວັນທີ ແລະເວລາຂອງກອງປະຊຸມເວທີສົນທະນາສາທາລະນະ Medi-Cal Rx ທັງໝົດແມ່ນຢູ່ລຸ່ມນີ້. ທຸກໆອົງການຈັດຕັ້ງທີ່ມີຄວາມສົນໃຈ, ລວມທັງແຕ່ບໍ່ຈໍາກັດ, ໂຮງຫມໍ, ຄລີນິກ, ແຜນສຸຂະພາບ, ເຂດປົກຄອງ, ຮ້ານຂາຍຢາ, ໂຄງການສຸຂະພາບຊົນເຜົ່າ, ແລະຜູ້ສະຫນັບສະຫນູນຜູ້ບໍລິໂພກ, ໄດ້ຖືກເຊື້ອເຊີນເຂົ້າຮ່ວມ.

ຕາຕະລາງເວທີສົນທະນາສາທາລະນະ Medi-Cal Rx

DHCS ຈະປ່ອຍຂໍ້ມູນເພີ່ມເຕີມເຊັ່ນດຽວກັນກັບການແຈ້ງເຕືອນຜ່ານລາຍຊື່ການແຈກຢາຍອີເມວຂອງຜູ້ມີສ່ວນກ່ຽວຂ້ອງຂອງ DHCS. ນອກຈາກນັ້ນ, DHCS ຍັງຈະປະກາດວາລະສຸດທ້າຍຢ່າງໜ້ອຍ 10 ມື້ກ່ອນກອງປະຊຸມແຕ່ລະຄັ້ງ.

Medi-Cal Rx: ຮວບຮວມ

All archived material from this page.

ຕິດຕໍ່ພວກເຮົາ

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

Medi-Cal Rx​​

ພາບລວມ​​

ຊັບພະຍາກອນແລະເອກະສານອ້າງອີງ​​

ການມີສ່ວນພົວພັນຂອງຜູ້ຖືຫຸ້ນ​​

ຄະນະທີ່ປຶກສາ Medi-Cal Rx​​

ຕາຕະລາງການປະຊຸມຂອງກຸ່ມທີ່ປຶກສາຂອງ Medi-Cal Rx​​

ເວທີປາໄສສາທາລະນະ Medi-Cal Rx​​

ຕາຕະລາງເວທີສົນທະນາສາທາລະນະ Medi-Cal Rx​​

Medi-Cal Rx: ຮວບຮວມ​​

ຕິດ​ຕໍ່​ພວກ​ເຮົາ​​