Medi-Cal Rx: Transition
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 Department of Health Care Services (DHCS) to transition all Medi-Cal pharmacy services from managed care (MC) to fee for service (FFS).
Transitioning pharmacy services from MC to FFS will, among other things:
- Standardize the Medi-Cal pharmacy benefit statewide, under one delivery system.
- 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".
Other changes resulting from the transition to FFS include:
- Apply statewide utilization management protocols to all outpatient drugs.
- Strengthen California's ability to negotiate state supplemental drug rebates with drug manufacturers.
Resources and Reference Materials
The following are resources and reference materials for beneficiaries and providers regarding Medi-Cal Rx services:
- 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 April 1, 2021, the secure portal
will give pharmacy providers, prescribers and their staff access to the Prior
Authorization system; beneficiary drug look-up tool; and web and batch claims
- Medi-Cal Rx Frequently Asked Questions (FAQs): Updated April 08, 2021, this document provides additional guidance and clarification to Medi-Cal beneficiaries, providers, plan partners, and other interested parties. 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 prior authorizations (PAs) from managed care and fee-for-service, as well as a 180-day period with no PA requirements for existing prescriptions, to help support the Medi-Cal Rx transition. During this transition period, Magellan will provide system messaging, reporting and outreach to provide for a smooth transition to Medi-Cal Rx.
Medi-Cal Rx Complaints and Grievances: Updated April 7, 2021, this document outlines DHCS' fee-for-service (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 April 8, 2021 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 will launch 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 they can access appropriate tools and resources for Medi-Cal Rx services that require access to protected health information (PHI).
- 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 (IVR) system to assist and resolve clinical pharmacy-related issues, as outlined in this document.
- Medi-Cal Rx Scope: Updated April 08, 2021, this document provides additional context and information related to the Department’s implementation of the Medi-Cal managed care to fee-for-service (FFS) pharmacy carve out, effective April 1, 2021. 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).
- Medi-Cal Rx Beneficiary Notice: This notice was sent to all Medi-Cal beneficiaries around April 1, 2021. The letter provides beneficiaries information regarding the delay of the planned Go-Live date of April 1, 2021 for Medi-Cal Rx.
As part of this transition, DHCS is committed to working with its external partners (including but not limited to, Managed Care Plans (MCPs), Counties, Providers, Consumer Advocates, and Beneficiaries) to ensure a smooth and successful transition through the following:
- Publicly releasing draft-informing materials (such as the Request for Proposal, provider and beneficiary notices, All Plan Letters, etc.) for comment.
- Ensuring MCPs, Counties, providers, consumer advocates, and beneficiaries receive timely and accurate information relating to the transition and associated implementation activities.
- Providing status updates and gathering stakeholder feedback through various DHCS-sponsored public meetings.
Note: In addition to stand-alone meetings, DHCS will be looking to leverage existing meetings and workgroups (e.g. stakeholder advisory committee, consumer stakeholder focus workgroup, Medi-Cal Medical Director’s meetings) to provide status updates on implementation efforts and activities related to Medi-Cal Rx.
For individuals with disabilities, the Department will provide assistive devices such as sign-language interpretation, real-time captioning, note takers, reading or writing assistance and conversion of training or meeting materials into Braille, large print, audiocassette, or computer disk. To request such services or copies in an alternate format, please call or write:
Department of Health Care Services
Pharmacy Benefits Division, MS 4604
Sacramento, CA 95814
Please note, the range of assistive services available may be limited if requests are received less than ten working days prior to the meeting or event.
Medi-Cal Rx Advisory Workgroup
The Medi-Cal Rx Advisory Workgroup will meet seven (7) times in-person between January 2020 and April 2021 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:
Roles and responsibilities of DHCS, the Medi-Cal Rx Contractor, and Medi-Cal Managed Care Plans
DHCS' implementation strategies, tools, and timelines, including but not limited to, provider education and outreach and beneficiary notifications
Medi-Cal pharmacy policy development, which will include the scope of the carve out, prior authorization, and utilization management protocols
Changes to existing Medi-Cal pharmacy committees
Post-transition, the Medi-Cal Rx Advisory Workgroup meetings will focus on gathering information, experiences and/or feedback from workgroup members to help refine Medi-Cal Rx processes and policies on an ongoing basis. The meetings will be open to the public, and in-person public comment will be accepted for the last 30 minutes of each meeting. Additional details, including but not limited to check-in and parking information, will be posted with the agenda at least 10 days prior to each meeting.
Medi-Cal Rx Advisory Workgroup Meeting schedule
Medi-Cal Rx Public Forum
Beginning in July 2019 and continuing throughout calendar year 2020, DHCS has hosted and will continue to host one (1) hour Medi-Cal Rx Public Forums in-person and via webinar to provide status updates to help ensure that the broader stakeholder community is kept up-to-date about Medi-Cal Rx implementation activities and timelines. All Medi-Cal Rx Public Forum meeting dates and times are listed below. All interested organizations and entities, including but not limited to, hospitals, clinics, health plans, counties, pharmacies, tribal health programs, and consumer advocates, are invited to participate.
Medi-Cal Rx Public Forum Schedule
- Meeting #9: April 14, 2021 (Wednesday) - Postponed
- Meeting #10: May 19, 2021 (Wednesday) - Postponed
DHCS will release additional information as well as reminder notices through various DHCS stakeholder email distribution lists. In addition, DHCS will also post a final agenda at least 10 days prior to each meeting.
For general questions relating to Medi-Cal Rx, please direct your comments and questions to RxCarveOut@dhcs.ca.gov.