Medi-Cal Rx: Paglipat ng Mga Serbisyo ng Botika ng Medi-Cal mula sa Managed Care tungo sa Fee-For-Service na Mga Madalas Itanong​​ 

Bersyon 16.0​​ 

Agosto 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.​​ 

Talaan ng mga Nilalaman​​ 

Pangkalahatang Impormasyon​​ 
Impormasyon sa Pagkuha​​ 
Impormasyon sa Transisyon​​ 
Mga Feed ng Data, Elektronikong Pag-access, at Iba Pang Mga Suporta sa Klinikal​​ 
Outreach, Edukasyon, at Pagsasanay ng Provider​​ 
Serbisyo sa Customer ng Benepisyaryo at Mga Kaugnay na Suporta​​ 
Pagiging Kwalipikado ng Benepisyaryo, Bahagi ng Gastos, at Iba Pang Mga Kaugnay na Tanong sa Saklaw sa Kalusugan​​ 
Medi-Cal Fee-For-Service Reimbursement Methodology​​ 
Mga Pagsasaalang-alang sa Patakaran​​ 
Paunang Awtorisasyon/ Pamamahala sa Paggamit​​ 
340B Federal Drug Discount Program​​ 
Mga Reklamo/ Karaingan ng Medi-Cal Rx Resolution at Mga Proseso ng Apela​​ 
Epekto sa Pananalapi/ Pagtatasa​​ 
Miscellaneous/ Ibang Impormasyon​​ 

Pangkalahatang Impormasyon​​ 

1. Why did the Department of Health Care Services (DHCS) transition the Medi-Cal pharmacy benefit from the Medi-Cal managed care delivery system to a fee-for-service delivery system?​​ 

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. Ano ang Medi-Cal Rx?​​ 

Medi-Cal Rx is the name the Department of Health Care Services (DHCS) has given to the collective pharmacy benefits and services that are administered through the fee-for-service delivery system by Magellan Medicaid Administration, LLC (MMA) as of full Assumption of Operations (AOO).​​  

3. Ano ang kinakatawan ng buong Medi-Cal Rx Assumption of Operations (AOO)?​​ 

Medi-Cal Rx AOO represents the date Magellan Medicaid Administration, LLC (MMA) assumed operational responsibility for all remaining administrative services necessary to support Medi-Cal Rx, including but not limited to claims management, prior authorization (PA) and utilization management (UM), provider and member support services, and other ancillary and reporting services. Medi-Cal Rx full AOO, as described in questions#23-25, took place on January 1, 2022. For additional details, please see questions #28-30.​​ 

4. Ano ang mga pakinabang ng paglipat ng mga benepisyo ng parmasya ng Medi-Cal mula sa pinamamahalaang pangangalaga patungo sa bayad-para-serbisyo?​​ 

Ang paglipat ng mga serbisyo ng parmasya mula sa pinamamahalaang pangangalaga ng Medi-Cal patungo sa bayad-para-serbisyo ay, bukod sa iba pang mga bagay ay:​​ 

• I-standardize ang benepisyo ng botika ng Medi-Cal sa buong estado, sa ilalim ng isang sistema ng paghahatid.​​ 
• 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.​​ 
• Applies statewide utilization management (UM) protocols to all outpatient drugs, as appropriate.​​ 
• 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. Kailangan bang humingi ng pederal na pag-apruba ang DHCS para ipatupad ang Medi-Cal Rx?​​ 

Oo. Ang DHCS ay humiling ng pederal na pag-apruba mula sa Centers for Medicare and Medicaid Services (CMS) upang ilipat ang mga benepisyo ng parmasya mula sa pinamamahalaang sistema ng paghahatid ng pangangalaga sa fee-for-service sa pamamagitan ng CalAIM Section 1915(b) wavier application. Ang waiver application ay sumasalamin sa carve-out ng mga benepisyo sa parmasya na sinisingil ng isang botika sa isang claim sa botika kabilang ang mga sakop na gamot sa outpatient at mga gamot na pinangangasiwaan ng doktor, gaya ng inilarawan sa Medi-Cal Rx All Plan Letter (APL20-020), epektibo sa Enero 1, 2022.​​ 

6. Anong Medi-Cal Managed Care Plans (MCPs) ang at hindi naaapektuhan ng Medi-Cal Rx?​​ 

All Medi-Cal MCPs, including AIDS Healthcare Foundation, are impacted. Medi-Cal Rx does not apply to Programs of All-Inclusive Care for the Elderly (PACE) plans, Senior Care Action Network (SCAN), or the 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 applies to both CCS and GHPP. Since the Medi-Cal Rx full Assumption of Operations (AOO), all requests for prior authorizations (PAs) (formally Service Authorization Requests or Treatment Authorization Requests, respectively) – for both independent and dependent counties, and CCS-only, GHPP-only, and CCS/GHPP Medi-Cal members – process through Medi-Cal Rx for pharmacy benefits billed on pharmacy claims.​​ 

As noted in question #24 below, DHCS maintains all drug coverage and policy responsibility as well as set all criteria relative to PA adjudication. Moreover, recognizing the specialized health care needs of the CCS/GHPP populations, DHCS continues to work closely and in partnership with the CCS Advisory Group and other key stakeholders in this space.​​ 

8. Ano ang hindi magbabago bilang bahagi ng Medi-Cal Rx?​​ 

Medi-Cal Rx did not change the following:​​ 

• The scope of the existing Medi-Cal pharmacy benefit.​​ 
• Ang pagbibigay ng mga serbisyo sa parmasya bilang bahagi ng isang bundle/all-inclusive na istraktura ng pagsingil sa isang inpatient o Long Term Care (LTC) na setting (kabilang ang Skilled Nursing Facilities [SNFs] at iba pang Intermediate Care Facility [ICFs]), anuman ang sistema ng paghahatid.​​ 
• Umiiral na Medi-Cal managed care pharmacy carve-outs (halimbawa, blood factor, HIV/AIDS drugs, antipsychotics, o mga gamot na ginagamit upang gamutin ang substance use disorder).​​ 
• Anumang mga serbisyo ng parmasya na sinisingil bilang isang medikal at/o institusyonal na claim sa halip na isang claim sa parmasya.​​ 
• Ang proseso ng State Fair Hearing (SFH), gaya ng tinukoy sa naaangkop na batas ng estado ng California.​​ 

9. Paano nakakaapekto ang Medi-Cal Rx sa pagbabayad ng mga gamot na ibinigay sa isang setting ng inpatient o long-term care (LTC)?​​ 

As noted in question #8, if a drug is provided as part of the bundled rate for services provided by an LTC/Skilled Nursing Facility (SNF), then it will remain the responsibility of the Medi-Cal Managed Care Plan (MCP). Otherwise, if prescription drugs are not part of the bundled rate for services provided by an LTC/SNF, and instead are billed on a fee-for-service basis, then the financial responsibility for those drugs is determined by the claim type on which they are billed. If the drugs are dispensed by a pharmacy and billed on a pharmacy claim, then they are carved out and paid by Medi-Cal Rx. If the drugs are furnished by the LTC/SNF and billed on a medical/institutional claim, the MCP is responsible, or the California Medicaid Management Information System (CA-MMIS) Fiscal Intermediary, if the member is in fee-for-service.​​ 

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

Medi-Cal Rx has taken over the responsibility from Medi-Cal Managed Care Plans (MCPs) for administering the following when billed by a pharmacy on a pharmacy claim:​​ 

• Mga Saklaw na Gamot sa Outpatient, kabilang ang ilang Physician Administered Drugs (PADs)​​ 
• Mga Tukoy na Kagamitang Medikal​​ 
• Mga Produktong Enteral Nutrition​​ 

Ang mga gamot na kasama sa mga serbisyong hindi nakalagay sa mga MCP (halimbawa, blood factor, mga gamot sa HIV/AIDS, antipsychotics, o mga gamot na ginagamit upang gamutin ang substance use disorder) ay nananatiling hindi nakalagay (carved out) anuman ang uri ng claim (iyon ay, parmasya o medikal na claim). Ang mga medikal na paghahabol para sa mga klase ng gamot na ito ay dapat na patuloy na isumite bilang bayad-para-sa-serbisyo na mga claim sa Medi-Cal Fiscal Intermediary (FI). Pinapaalalahanan ang mga medikal na provider na ang mga gamot na hindi nakalista sa Contract Drugs List (CDL) ng botika at pinangangasiwaan ng isang
na hindi nakabatay sa parmasya na medikal na propesyonal sa pangangalagang pangkalusugan ay karaniwang dapat singilin bilang mga medikal na claim ng nangangasiwa na provider at hindi sinisingil ng isang parmasya.​​ 

New additions to the list of noncapitated classes of drugs carve-out list typically take at least 60 days before claims can be successfully billed. Providers are asked to hold their claims until the system is ready to accept them.​​  

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. Paano lalapit ang DHCS sa saklaw ng mga supply para sa diabetes, na kinabibilangan ng mga test strip, lancet, glucometer, control solution, at lancing device, pagkatapos ng Medi-Cal Rx full Assumption of Operations (AOO)?​​ 

The diabetic test strips (for urine, blood glucose, and ketones) and lancets benefit policy did not change under Medi-Cal Rx and is subject to the list of contracted products and the criteria currently published in the Medical Supplies section of the Medi-Cal Provider Manual.​​  

Ang impormasyong ito ay makukuha sa Medi-Cal Rx Provider Manual at sa Medi-Cal Rx Web Portal.​​ 

Specific Glucometers, Control Solutions, and Lancing Devices are pharmacy-billed medical supply benefit through Medi-Cal Rx, effective January 1, 2022, and are restricted to the products on the newly created List of Covered Self-Monitoring Blood Glucose Systems (Glucometers), Control Solutions, and Lancing Devices (available on the Medi-Cal Rx Web Portal) for Medi-Cal R coverage consideration as a pharmacy benefit. Applicable products within this category that are not on this list are considered ineligible for coverage consideration by Medi-Cal Rx as a pharmacy benefit.​​ 

Ang mga produktong hindi kinontrata na hindi matatagpuan sa Listahan ng Mga Sakop na Self-Monitoring Blood Glucose System (Glucometers), Control Solutions, at Lancing Device ay maaaring ibalik sa pamamagitan ng alinman sa Medi-Cal Managed Care Plans (MCPs) o ang fee-for-service Fiscal Intermediary (FI) bilang isang benepisyo sa Durable Medical Equipment (DME) na sinisingil ng HCPCS. Ang mga paghihigpit sa dami ay nananatiling hindi nagbabago.​​ 

12. How does DHCS currently approach coverage of disposable external ambulatory insulin delivery systems (Omnipod and V-Go) and has that changed since the Medi-Cal Rx full 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.​​ 

Ang mga DIDD ay nangangailangan ng paunang awtorisasyon (PA) para sa reimbursement at nalalapat ang mga partikular na pamantayan sa saklaw. Ang mga DIDD ay kasama sa patakaran sa paglipat. Para sa mga claim na dati nang binayaran bilang benepisyong medikal na sinisingil sa isang form na CMS-1500 , dapat isama ng mga provider ang aktibong PA na dati nang isinumite kasama ang claim sa benepisyong medikal at nakasulat na katwiran para sa pagpapatuloy ng therapy kapag nagsumite sila ng claim sa parmasya para sa hiniling na produkto upang matiyak na natutugunan ang mga kinakailangan sa saklaw.​​ 

13. How does DHCS approach coverage of Continuous Glucose Monitors (CGMs), other durable medical equipment (DME), DME supplies and disposable medical supplies, after the Medi-Cal Rx full 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.​​ 

Para sa mga benepisyaryo ng Fee-for-Service (FFS) Medi-Cal, simula Oktubre 1, 2022, ang mga claim na dati nang binayaran bilang benepisyong medikal na sinisingil sa isang form ng CMS 1500 sa pamamagitan ng isang HCPCS code ay dapat isumite bilang isang claim sa parmasya sa Medi-Cal Rx. Tatanggihan ng mga HCPCS code na ito ang mga medikal na claim na isinumite na may petsa ng serbisyo pagkatapos ng Disyembre 1, 2022.​​ 

Tandaan: Ang mga kaukulang insulin pump para sa ilang CGM device ay mananatiling isang DME na masisingil bilang isang benepisyong medikal na sinisingil sa isang form ng CMS 1500 sa pamamagitan ng isang HCPCS code. Sumangguni sa seksyong DME ng manwal ng tagapagkaloob ng botika ng Medi-Cal sa website ng Mga Provider ng Medi-Cal para sa saklaw at impormasyon sa pagsingil sa mga DME insulin pump at accessories.​​ 

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. Paano lalapit ang DHCS sa pagsaklaw ng iba pang mga benepisyo ng mga medikal na supply sa kasalukuyan o dati nang sinisingil bilang isang medikal na claim, sa pamamagitan ng HCPCS code at sa isang CMS-1500 form, pagkatapos ng Medi-Cal Rx full 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. Kasama ba sa Medi-Cal Rx ang mga benepisyo sa parmasya na sinisingil sa mga medikal at/o institusyonal na paghahabol?​​ 

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. Paano ire-reimburse ng Medi-Cal ang mga provider para sa pangangasiwa ng bakuna sa 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.​​ 

Impormasyon sa Pagkuha​​ 

20. How did the Department of Health Care Services administer Medi-Cal Rx?​​ 

DHCS released Request for Proposal (RFP) #19-96125 on August 22, 2019, to procure an administrative services contractor to administer the Medi-Cal fee-for-service pharmacy services for, at the time, more than 13.5 million Medi-Cal members. On December 13, 2019, DHCS awarded a contract to Magellan Medicaid Administration, LLC (MMA) to provide a comprehensive suite of administrative services as directed by DHCS, which include but are not limited to claims management, prior authorization (PA) and utilization management (UM), pharmacy drug rebate administration, provider and member support services, and other ancillary and reporting services to support the administration of the Medi-Cal pharmacy benefit.​​ 

21. Ano ang timeline ng pagkuha ng Medi-Cal Rx?​​ 

Ang timeline para sa mga pagsisikap na nauugnay sa pagkuha ng Medi-Cal Rx ay ang mga sumusunod:​​  

• July 22, 2019: Draft Medi-Cal Rx Request for Proposal (RFP) #19-96125 released for a two-week public comment period.​​ 
• August 22, 2019: Final Medi-Cal Rx RFP #19-96125 released.​​ 
• August 29, 2019: Final Medi-Cal Rx RFP #19-96125 questions due to the Department of Health Care Services (DHCS).​​ 
• September 17, 2019: Answers to questions related to the Final Medi-Cal Rx RFP #19-96125 and addenda posted.​​ 
• October 1, 2019: All Medi-Cal Rx RFP #19-96125 proposals due.​​ 
• November 7, 2019: Notice of Intent to Award posted to the DHCS website.​​ 
• December 13, 2019: DHCS awarded contract to Magellan Medicaid Administration, LLC (MMA).​​ 
• December 20, 2019: Contract Effective Date.​​ 
• January 1, 2022: Medi-Cal Rx Full Assumption of Operations (AOO) took place.​​ 

22. Sino ang Medi-Cal Rx Contractor na pinili sa pamamagitan ng proseso ng pagkuha?​​ 

The Medi-Cal Rx Contractor selected to administer Medi-Cal fee-for-service pharmacy services is 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)?​​ 

Ang mga MCP ng Medi-Cal ay magiging responsable para sa mga aktibidad kabilang ang, ngunit hindi limitado sa, ang mga sumusunod:​​ 

• Overseeing and maintaining all activities necessary for enrolled Medi-Cal member care coordination and related activities, consistent with contractual obligations.​​ 
• Pagbibigay ng pangangasiwa at pamamahala sa lahat ng klinikal na aspeto ng pagsunod sa parmasya, kabilang ang pagbibigay ng sakit at pamamahala ng gamot.​​ 
• Pagproseso at pagbabayad ng lahat ng serbisyo ng parmasya na sinisingil sa mga medikal at institusyonal na paghahabol.​​ 
• Paglahok sa mga pulong na may kaugnayan sa Medi-Cal Global Drug Use Review (DUR) Board at iba pang mga pulong ng komite ng botika na hinimok ng Department of Health Care Services (DHCS).​​ 
• Ang patuloy at patuloy na paglahok sa post-claim adjudication na aktibidad ng DUR gaya ng Retrospective DUR (RetroDUR) (kung kinakailangan para sa koordinasyon ng pangangalaga), mga programang pang-edukasyon, at pagsusumite ng taunang ulat ng DUR.​​ 

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

Ang DHCS ay magiging responsable para sa mga aktibidad kabilang ang, ngunit hindi limitado sa, ang mga sumusunod:​​ 

• Pagbuo, pagpapatupad, at pagpapanatili ng lahat ng patakaran sa parmasya ng Medi-Cal, kabilang ang, ngunit hindi limitado sa:​​ 
  • Pagsakop sa droga​​ 
  • Mga karagdagang rebate sa gamot ng estado​​ 
  • Paunang awtorisasyon (PA)/pamamahala sa paggamit (UM)​​ 
• Negosasyon ng, at pagkontrata para sa, mga karagdagang rebate sa gamot ng estado.​​ 
• 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).​​ 
• Pagbibigay ng pangangasiwa sa, at pagpapadali para sa, proseso ng State Fair Hearing (SFH).​​ 
• Establishing Medi-Cal Rx pharmacy reimbursement methodologies, consistent with applicable state and federal requirements.​​ 
• Pagtatatag at pagpapanatili ng network ng provider ng parmasya ng Medi-Cal.​​ 
• Pangangasiwa sa Medi-Cal Global Drug Use Review (DUR) Board at iba pang komite ng parmasya na pinapatakbo ng Department, sa pakikipagtulungan ng Magellan Medicaid Administration, LLC (MMA).​​ 
• Pamamahala ng kontrata at pangangasiwa/pagsubaybay ng 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) will be responsible for activities including, but not limited to, the following:​​  

• Providing a Medi-Cal Rx Customer Service Center (CSC) that is available 24 hours a day, 7 days a week, 365 days per year, excluding approved holidays, or unless otherwise directed by the Department of Health Care Services (DHCS), to support all provider and member calls, as well as provide outreach, training, and informing materials.​​ 
• Pagbibigay ng mga direktang pakikipag-ugnayan ng Medi-Cal Managed Care Plan (MCP) upang tumulong sa koordinasyon ng pangangalaga at mga klinikal na isyu.​​ 
• 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.​​ 
• Nagbibigay ng mga pagpapaandar ng pangangasiwa, pagproseso, at pagbabayad ng mga claim para sa lahat ng serbisyo ng parmasya na sinisingil sa mga claim sa parmasya.​​ 
• Pangangasiwa sa koordinasyon ng mga benepisyo (COB) sa iba pang saklaw sa kalusugan, kabilang ang 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.​​ 
• Pagbibigay ng mga serbisyong Prospective at Retrospective Drug Use Review (DUR).​​ 
• Ang pagbibigay ng mga data feed (kahit araw-araw) sa Medi-Cal MCPs upang suportahan ang kanilang mga responsibilidad sa pag-uugnay sa pangangalaga ng miyembro, pagsasagawa ng mga klinikal na aspeto ng pagsunod sa parmasya, at pamamahala sa sakit at gamot.​​ 
• 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. How does the Department of Health Care Services ensure that the Medi-Cal Rx Contractor does not use patient data, including prescription information, for any purpose other than Medi-Cal Rx administrative services?​​ 

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. Saan ako makakahanap ng higit pang impormasyon tungkol sa Medi-Cal Rx Request for Proposal #19-96125?​​ 

Para sa karagdagang impormasyon tungkol sa Medi-Cal Rx Request for Proposal #19-96125, pakibisita ang FI$Cal/Cal eProcure website. Ang mga huling panukala ay nakatakda sa Oktubre 1, 2019 sa 4 pm PDT. Ang proseso ng pagkuha ay sarado na ngayon.​​ 

Impormasyon sa Transisyon​​ 

28. Kailan magaganap ang buong Assumption of Operations (AOO) ng Medi-Cal Rx?​​ 

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. Bakit naantala ang nakaplanong petsa ng Go-Live noong Abril 1, 2021 para sa buong Assumption of Operations ng Medi-Cal Rx?​​ 

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.​​ 

In January 2021, Centene Corporation announced that it planned to acquire Magellan. Centene operates – through subsidiaries – Managed Care Plans (MCPs) and pharmacies that participate in Medi-Cal. This transaction was unexpected and required additional time for exploration of acceptable conflict avoidance protocols to ensure that there were acceptable firewalls between the corporate entities to protect the pharmacy claims data of all Medi-Cal members, and to protect other proprietary information.​​ 

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:​​ 

• Allowed Medi-Cal providers, Managed Care Plans (MCPs), and other interested parties to register for the Medi-Cal Rx secure portals and participate in comprehensive trainings that ensured greater overall understanding of the project and supported operational readiness for providers and MCPs.​​ 
• Stood up and mobilized the Medi-Cal Rx Customer Service Center (CSC) to allow experts at the CSC to field and answer questions from Medi-Cal members, providers, MCPs, and other interested parties, potentially preempting confusion and other potential challenges once the full implementation of Medi-Cal Rx occurred. While the CSC experts were not providing the full suite of services prior to AOO, they were after the
  Medi-Cal Rx full AOO. They were able to provide important TSS, including proactive outreach to providers, as well as targeted assistance and critical information, relative to Medi-Cal Rx tools and functionalities.​​ 
• Provided additional time for MCPs to interact with and build rapport with dedicated Medi-Cal Rx clinical liaisons, who helped MMA build accurate and comprehensive MCP profiles to ensure that the individualized needs of the populations served by each MCP continue to be met.​​ 
• 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.​​ 

After the Medi-Cal Rx full AOO, MMA assumed responsibility for all remaining administrative services necessary to support Medi-Cal Rx, including, but not limited to, the following:​​ 

• Ang pagpapalawig ng mga oras ng CSC sa 24 na oras sa isang araw, 7 araw sa isang linggo, 365 araw bawat taon, hindi kasama ang mga inaprubahang holiday, o maliban kung itinuro ng DHCS, upang suportahan ang lahat ng mga tawag sa provider at miyembro, pati na rin ang outreach, pagsasanay, at mga materyales sa pagbibigay-alam.​​ 
• Pamamahala ng mga paghahabol, paunang awtorisasyon (PA) at pamamahala sa paggamit (UM), mga serbisyo ng suporta sa provider at miyembro, at iba pang mga serbisyong pantulong at pag-uulat.​​  

Para sa karagdagang mga detalye, pakitingnan ang mga tanong #23-25.​​ 

31. How did DHCS ensure that the knowledge and experience of Medi-Cal Managed Care Plans (MCPs), and other stakeholders, is leveraged in the transition process to achieve a successful continuity of services?​​ 

Ang DHCS ay aktibong nakipag-ugnayan sa mga panlabas na kasosyo sa maraming paraan at sa maraming paraan upang matiyak na ang kaalaman at karanasan ay magagamit upang maging matagumpay ang Medi-Cal Rx. Nilalayon ng DHCS na ipagpatuloy ang mga ganitong uri ng pagsisikap sa pakikipag-ugnayan at nakatuon sa pakikipagtulungan sa mga panlabas na kasosyo nito, kabilang ang mga Medi-Cal MCP, county, provider, tagapagtaguyod ng consumer, at mga benepisyaryo, upang matiyak ang maayos at matagumpay na paglipat. Halimbawa, ang DHCS ay nagtatag ng isang nakatuong Medi-Cal MCP Workgroup at isang Medi-Cal Rx Advisory Workgroup na binubuo ng iba't ibang kinatawan ng stakeholder na regular na nagpupulong upang talakayin ang iba't ibang isyu, tukuyin ang pinakamahuhusay na kagawian, at magbigay ng mga magagamit na solusyon at estratehiya upang suportahan ang mga pagsisikap sa pagpapatupad ng DHCS.​​ 

Sa pagpapatuloy, ang DHCS ay patuloy ding aktibong tuklasin ang mga pagkakataon upang i-streamline at pahusayin ang kasalukuyang pakikipag-ugnayan ng stakeholder at mga pagsisikap sa outreach sa paligid ng Medi-Cal, na kinabibilangan ng mga naka-target na Medi-Cal Rx workgroup na pagpupulong at mga talakayan upang makipagtulungan sa pinakamahuhusay na kasanayan at mga diskarte sa pagpapatupad na tumutugon sa mga pangangailangan ng lahat ng apektadong partido.​​ 

32. Paano ipapaalam ang impormasyon tungkol sa paglipat ng Medi-Cal Rx at iba pang kaugnay na mga pagbabago?​​ 

Makikipagtulungan ang DHCS sa MMA upang matiyak na ang lahat ng mga interesadong partido (kabilang ang, ngunit hindi limitado sa, Medi-Cal MCPs, Mental Health Plans, Substance Use Disorder Plans, provider, at benepisyaryo) ay naaabisuhan tungkol sa paglipat at iba pang nauugnay na pagbabago.​​ 

Ang komunikasyon ay ipapalaganap sa pamamagitan ng ilang mga pamamaraan kabilang ang, ngunit hindi limitado sa, ang mga sumusunod:​​ 

• Isang bagong Medi-Cal Rx Web Portal na inilunsad noong Hunyo 2020 at nagsisilbing isang platform upang turuan at ipaalam ang mga magagamit na mapagkukunan, impormasyon, at mga pagbabago sa mga interesadong partido. Ang nilalamang pang-edukasyon at mga madalas itanong ay nai-post at madalas na ina-update.​​ 
• Simula noong Hunyo 2020, ginawang available ang Medi-Cal Rx Subscription Service (MCRxSS) mula sa Medi-Cal Rx Web Portal upang payagan ang mga interesadong partido na mag-sign up at makatanggap ng mga regular na update sa Medi-Cal Rx sa pamamagitan ng email.​​ 
• Mula Agosto 2020, makikita ng mga interesadong partido ang mga bulletin tungkol sa mga pagbabagong nai-post sa Medi-Cal Rx Web Portal.​​ 
• Isang serye ng mga pagsasanay at materyal na pang-edukasyon para sa mga tagapagbigay ng Medi-Cal at MCP ay makukuha mula sa bagong website ng Medi-Cal Rx. Ang mga MCP at provider ay may kakayahang mag-sign up para sa mga kaganapan sa pagsasanay at edukasyon mula noong Setyembre 2020.​​ 
• Ang mga abiso sa mga benepisyaryo ng Medi-Cal sa parehong mga MCP at mga sistema ng paghahatid ng bayad para sa serbisyo ay ipinadala sa o mga Oktubre 1, 2020, Nobyembre 1, 2020, at Disyembre 15, 2020. Ang mga abiso sa mga benepisyaryo ng Medi-Cal ay ipinadala rin simula noong huling bahagi ng Marso 2021 na nagpapaalam sa kanila ng pagkaantala sa Medi-Cal Rx full Assumption of Operations (AOO). Ang mga karagdagang paunawa sa mga benepisyaryo ng Medi-Cal ay ipinadala sa o mga Nobyembre 1, 2021, na nag-aanunsyo ng AOO noong Enero 1, 2022.​​ 
• Isang Medi-Cal MCP Medi-Cal Rx Outreach Campaign, na isinasagawa sa pamamagitan ng tradisyunal na outbound call campaign o iba pang alternatibong paraan ng komunikasyon, ayon sa inaprubahan ng DHCS, sa mga naka-enroll na miyembro.​​ 
• Mga update sa Handbook ng Miyembro ng Medi-Cal Managed Care Plan (Ebidensya ng Saklaw), pati na rin ang mga materyales sa pagpapaalam para sa iba pang mga naapektuhang entity.​​ 
• Mga update sa Medi-Cal Provider Manual, pati na rin ang bagong gabay ng provider at mga materyales na inilathala ng MMA, ayon sa direksyon ng DHCS.​​ 
• Mga update sa mga kontrata ng Medi-Cal MCP, kung kinakailangan, upang ipakita ang paglipat ng benepisyo ng parmasya mula sa pinamamahalaang pangangalaga patungo sa bayad-para-serbisyo.​​ 
• Paglikha ng bagong Liham ng Medi-Cal Rx All Plan para sa mga MCP, at iba pang nauugnay na mga paunawa sa impormasyon para sa mga provider na nakabase sa county at iba pang pangunahing kasosyo sa antas ng county.​​ 
• Paglikha ng bagong Departamento ng Managed Health Care All Plan Letter, na nauugnay sa Medi-Cal Rx, para sa Medi-Cal MCPs na nagbibigay ng patnubay mula sa isang perspektibo sa regulasyon, pagsunod, at pag-file.​​ 
• Mga update sa mga rate ng Medi-Cal MCP.​​ 
• 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. Paano titiyakin ng DHCS na ang mga benepisyaryo ng Medi-Cal na lumilipat sa Medi-Cal Rx ay hindi makakaranas ng pagkagambala sa kanilang pangangalaga at/o kawalan ng kakayahan na ma-access ang mga kinakailangang iniresetang gamot?​​ 

Upang matulungan ang mga benepisyaryo ng Medi-Cal, mga tagapagbigay ng serbisyo (mga tagareseta at parmasya), at mga Managed Care Plan (MCP) sa buong Assumption of Operations (AOO) ng Medi-Cal Rx, magbibigay ang DHCS ng iba't ibang Medi-Cal Rx Transitional Supports and Services (TSS) sa pagitan ng Enero 1, 2021, hanggang sa buong AOO ng Medi-Cal Rx sa Enero 1, 2022, gaya ng mas detalyadong inilarawan sa tanong #30 sa itaas at bumuo at magpapatupad ng isang patakaran sa paglipat sa parmasya na may maraming aspeto. Ang patakaran sa transisyon sa parmasya ay gagamit ng mga estratehiya tulad ng "grandfathering" sa mga naunang inaprubahang kahilingan para sa paunang pahintulot (PA) sa pamamagitan ng kanilang nakasaad na tagal, na hindi hihigit sa isang (1) buong taon mula sa petsa ng pagsulat ng reseta, maliban kung ang gamot ay kasama sa listahan ng mga eksepsiyon na nagpapahintulot sa pinalawig/maraming-taong PA hanggang limang (5) taon para sa ilang partikular na klase/kategorya ng gamot. Kasama rin sa panahon ng transisyon ang 180-araw na panahon kung saan hindi na hihingin ng DHCS ang PA para sa mga kasalukuyang reseta na walang dating inaprubahang PA mula sa kanilang naaangkop na Medi-Cal MCP, para sa mga gamot na wala sa Medi-Cal Contract Drugs List (CDL), o mga gamot na may mga kinakailangan sa PA sa ilalim ng Medi-Cal Rx. Hindi nalalapat ang patakarang ito sa mga bagong reseta o gamot na walang mga kinakailangan sa PA sa ilalim ng Medi-Cal Rx. Sa panahong ito ng transisyon, magbibigay ang Magellan ng sistema ng pagmemensahe, pag-uulat, at pakikipag-ugnayan upang magkaroon ng maayos na paglipat sa Medi-Cal Rx. Ang panahong ito ng transisyon sa parmasya ay magpapadali sa isang maayos at produktibong transisyon, na titiyak na ang mga benepisyaryo ng Medi-Cal ay hindi makakaranas ng pagkaantala sa kanilang pag-access sa mga reseta na kinakailangang medikal habang pinapanatili ang pagsunod sa lahat ng batas ng estado at pederal na may kaugnayan sa benepisyo ng parmasya ng Medi-Cal. Ang Patakaran sa Paglipat sa Parmasya ng DHCS ay makukuha sa webpage ng Medi-Cal Rx Transition.​​ 

34. Bubuo ba ang DHCS ng plano ng paglipat ng Medi-Cal Rx, at, kung gayon, anong mga bahagi ang isasama sa planong iyon?​​ 

Yes, pursuant to the requirements outlined in Request for Proposal #19-96125, Exhibit A, Attachment I – Scope of Work – Takeover, Magellan Medicaid Administration,  LLC (MMA) and DHCS will develop a Medi‑Cal Rx pharmacy transition approach/plan to include, at a minimum, processes for:​​ 

• Pagbibigay ng sapat na paunawa at kakayahang umangkop para sa mga parmasya at tagapagreseta ng Medi-Cal na gawin ang lahat ng kinakailangang hakbang upang masanay sa bagong Kontratista ng Medi-Cal Rx, ang Medi-Cal Contract Drugs List (CDL), at mga nauugnay na proseso.​​ 
• Pagbibigay ng naaangkop na paunawa at mga nauugnay na materyales mula sa DHCS at Medi-Cal Managed Care Plans (MCPs) sa mga benepisyaryo ng Medi-Cal tungkol sa paglipat.​​ 
• Providing direction for obtaining prior authorization (PA) on drugs dispensed during the transition period by allowing ongoing (drug treatments initiated prior to Medi-Cal Rx full Assumption of Operations [AOO]) drugs to be dispensed and billed without first having an approved PA. However, prospective Drug Use Review (DUR) requirements for drug safety will still apply.​​ 
• Tulong sa botika, provider, at benepisyaryo, kabilang ang pagtiyak na ang mga apektadong partido ay makakatanggap ng naaangkop na abiso ng, at karagdagang impormasyon na nauugnay sa, panahon ng transisyonal na parmasya ng Medi-Cal Rx at mga kaugnay na proseso.​​ 

35. Anong mga diskarte ang gagamitin ng DHCS sa plano ng paglipat ng Medi-Cal Rx upang matiyak ang maayos at epektibong paglipat sa Medi-Cal Rx para sa mga benepisyaryo?​​ 

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. Dapat bang ihinto at/o ipawalang-bisa ng Medi-Cal Managed Care Plans (MCPs) ang anumang mga naunang awtorisasyon (PA) na hinatulan at inaprubahan ng Medi-Cal MCP sa o bago ang Medi-Cal Rx full Assumption of Operations (AOO)?​​ 

Hindi, ang mga Medi-Cal MCP ay hindi dapat ihinto at/o i-void ang mga naturang PA at hindi dapat magkaroon ng mga awtorisasyon na awtomatikong mawawalan ng bisa isang araw bago ang buong AOO ng Medi-Cal Rx. Ang mga MCP ng DHCS at Medi-Cal ay dapat gumawa ng mga kinakailangang hakbang upang matiyak na ang mga benepisyaryo ng Medi-Cal ay patuloy na magkakaroon ng access sa mga benepisyo at serbisyo sa parmasya na medikal na kinakailangan sa panahon ng paglipat sa Medi-Cal Rx.​​ 

Mga Feed ng Data, Elektronikong Pag-access, at Iba Pang Mga Suporta sa Klinikal​​ 

37. Magbibigay ba ang Medi-Cal Rx ng data ng parmasya at kinakailangang elektronikong pag-access para sa mga provider ng Medi-Cal, Medi-Cal Managed Care Plans (MCPs), at iba pang entity upang suportahan ang koordinasyon ng pangangalaga?​​ 

Oo, magbibigay ang Medi-Cal Rx ng mga data feed (kahit araw-araw) sa mga MCP ng Medi-Cal upang suportahan ang kanilang mga responsibilidad sa koordinasyon ng pangangalaga ng benepisyaryo, pagsasagawa ng mga klinikal na aspeto ng pagsunod sa parmasya, at pamamahala sa sakit at gamot. Ang DHCS ay patuloy na nag-e-explore ng mga opsyon at rekomendasyon na may kaugnayan sa mga data feed para sa Mental Health at Substance Use Disorder Plans at makikipag-ugnayan sa mga pangunahing stakeholder sa espasyong ito. Ang anumang napagkasunduang solusyon ay ipapatupad pagkatapos ng buong Assumption of Operations ng Medi-Cal Rx.​​ 

Bilang karagdagan, ang Medi-Cal Rx ay magbibigay ng naaangkop na real-time na pag-access sa elektronikong kapaligiran ng MMA sa pamamagitan ng isang secure na portal sa lahat ng mga provider ng Medi-Cal (mga tagapagbigay ng reseta at parmasya) at Medi-Cal MCP, Mental Health at Mga Plano sa Disorder sa Paggamit ng Substansya, at mga karagdagang entity na itinalaga ng DHCS.​​ 

38. Anong karagdagang suporta sa koordinasyon ng klinikal at pangangalaga ang ibibigay ng Medi-Cal Rx sa Medi-Cal Managed Care Plans (MCPs)?​​ 

Magbibigay ang MMA ng karagdagang suporta sa koordinasyon ng klinikal at pangangalaga sa mga MCP ng Medi-Cal upang matugunan ang kanilang mga obligasyon sa kontraktwal na may kaugnayan sa koordinasyon sa pangangalaga ng benepisyaryo ng Medi-Cal, pagsunod sa gamot, at iba pang mga kaugnay na responsibilidad, sa pamamagitan ng:​​ 

• 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.​​ 
• Pagpapanatili ng sapat na mga ratios ng staffing ng mga nakalaang Medi-Cal MCP clinical liaisons upang matiyak na ang antas ng access na ito ay pinananatili para sa Medi-Cal MCPs.​​ 
• Nagbibigay ng access sa mga klinikal na tagapag-ugnay ng Medi-Cal MCP sa pamamagitan ng nakalaang Integrated Voice Response system ng Medi-Cal Rx upang tumulong at malutas ang mga isyung may kaugnayan sa klinikal na parmasya.​​ 

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

Outreach, Edukasyon, at Pagsasanay ng Provider​​ 

39. Anong mga uri ng provider ng outreach, edukasyon, at pagsasanay, pati na rin ang mga kaugnay na suporta, ang inaalok at/o pinaplanong gawin ng DHCS para sa Medi-Cal Rx?​​ 

Ang DHCS, sa pakikipagtulungan sa MMA, ay nakatuon sa pagbibigay ng mga serbisyo ng suporta sa customer ng provider ng Medi-Cal, kabilang ngunit hindi limitado sa mga sumusunod:​​ 

• Isang Customer Service Center (CSC) upang suportahan ang lahat ng mga tawag sa provider, dalawampu't apat (24) na oras bawat araw, pitong (7) araw bawat linggo, tatlong daan at animnapu't limang (365) araw bawat taon, hindi kasama ang mga inaprubahang holiday, o maliban kung itinuro ng DHCS.​​ 
• Outreach, pagsasanay, at mga materyales sa pagpapaalam sa mga tagapagbigay ng Medi-Cal, Medi-Cal Managed Care Plans (MCPs), at iba pang entity.​​ 
• Mga serbisyong nakabatay sa web upang suportahan ang komunikasyon at mga tool para sa Medi-Cal Rx.​​ 
• Real-time access into MMA’s electronic environment via a secure portal.​​ 
• Iba pang mga serbisyo at suporta upang matiyak ang maayos at epektibong paglipat (hal., Medi-Cal Rx transitional supports and services (TSS) at 180-araw na pharmacy transitional period).​​ 

Bilang karagdagan, ang mga Kinatawan ng Medi-Cal Rx CSC ng MMA ay kikilos sa ngalan ng DHCS upang maghatid at magbigay ng kadalubhasaan/suporta sa paksa tungkol sa impormasyon ng Medi-Cal Rx at mga materyales sa pagsasanay sa mga provider (mga tagapagreseta at parmasya) na ahente sa pagsingil ng parmasya, at mga kasosyo sa plano, sa iba't ibang lugar. Para sa karagdagang impormasyon, pakitingnan ang Kahilingan para sa Panukala #19-96125 Exhibit A, Attachment II – Saklaw ng Trabaho – Mga Operasyon – Edukasyon at 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.​​ 

Member Customer Service & Related Supports​​ 

39. Anong Mga Uri ng serbisyo sa customer ng benepisyaryo ng Medi-Cal at mga kaugnay na suporta ang inaalok at/o pinaplanong gawin ng DHCS para sa Medi-Cal Rx?​​ 

Ang DHCS, sa pakikipagtulungan sa Magellan Medicaid Administration, LLC (MMA), ay nakatuon sa pagbibigay ng serbisyo sa customer ng miyembro at mga kaugnay na suporta, kabilang ngunit hindi limitado sa mga sumusunod:​​ 

• The Medi-Cal Rx Customer Service Center (CSC) supporting all member calls, 24 hours a day, 7 days a week, 365 days per year, excluding approved holidays, or unless otherwise directed by DHCS.​​ 
• Informing materials related to Medi-Cal Rx through different avenues, including but not limited to appropriate notices via U.S. Mail and web-based services (for example, external facing websites to support communication and tools for 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.​​ 
• Isang interactive voice response (IVR) system na magbibigay ng:​​ 
  • Naka-record na impormasyon​​ 
  • Mga pagpipilian sa self-service​​ 
  • Kakayahang humiling ng follow-up mula sa customer service, tulad ng callback na tawag sa telepono o impormasyong ibibigay sa pamamagitan ng mail o 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.​​ 

Pagiging Kwalipikado ng Miyembro, Bahagi ng Gastos, at Iba Pang Mga Kaugnay na Tanong sa Saklaw sa Kalusugan​​ 

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. Kapag ang mga benepisyaryo ng Medi-Cal ay may Other Health Coverage (OHC), aling coverage sa kalusugan at pakete ng mga benepisyo ang itinuturing na pangunahin?​​ 

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

44. Maaapektuhan ba ng Medi-Cal Rx ang mga benepisyaryo ng Medi-Cal na parehong may saklaw ng Medi-Cal at Medicare (Bahagi D)?​​ 

Hindi. Hindi naaapektuhan o binabago ng Medi-Cal Rx ang anumang saklaw ng gamot para sa mga benepisyaryo ng Medi-Cal na parehong may saklaw ng Medi-Cal at Medicare (Bahagi D). Maaaring saklawin ng Medi-Cal ang mga benepisyo ng inireresetang gamot na maaaring hindi ng Medicare (Bahagi D), kaya dapat ding talakayin ng mga benepisyaryo ng Medi-Cal sa kanilang mga provider.​​ 

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

45. Para sa mga parmasya ng Medi-Cal, paano itinatag ang pamamaraan ng pagbabayad ng bayad-para-sa-serbisyo ng parmasya ng Medi-Cal, at ano ang mga bahagi?​​ 

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. Kinakalkula ng Department of Health Care Services (DHCS) ang halaga ng sangkap ng gamot bilang pinakamababa sa:​​ 
   • ang National Average Drug Acquisition Cost (NADAC) ng gamot, o kapag walang available na NADAC, ang Wholesale Acquisition Cost (WAC) + 0%, o​​ 
   • ang Federal Upper Limit (FUL), o​​ 
   • ang Maximum Allowable Ingredient Cost (MAIC).​​ 
2.  Isang propesyonal na bayad sa dispensing (two-tiered batay sa kabuuang Medicaid at non-Medicaid taunang dami ng paghahabol sa parmasya [iyon ay, mga ibinibigay na reseta]):​​ 
   • > o = 90,000 claim bawat taon: $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​​ 

Mga Pagsasaalang-alang sa Patakaran​​ 

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:​​ 

• Lahat ng inaprubahan ng US Food and Drug Administration (FDA) na mga sakop na gamot sa outpatient, gaya ng tinukoy ng Centers for Medicare & Medicaid Services (CMS), na napapailalim sa medikal na pangangailangan.​​ 
• 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. Paano gumagawa ng mga pagpapasiya ang DHCS na magdagdag o magtanggal ng mga gamot mula sa Contract Drugs List (CDL)?​​ 

Maaaring magdagdag ng mga gamot ang DHCS sa Medi-Cal CDL batay sa pagtanggap ng alinman sa (1) isang panlabas na kahilingan sa Indibidwal na Drug Petition (IDP) mula sa isang tagagawa, manggagamot, at/o parmasyutiko, o (2) isang pagsusuri sa IDP na pinasimulan ng DHCS, kung naaangkop. Kapag natanggap na ang isang IDP, nagsasagawa ang DHCS ng malawakang pagsusuri sa kahilingan, na isinasaalang-alang ang mga literatura na nakabatay sa ebidensya, pinakamahuhusay na kagawian sa industriya, at ang mga sumusunod na pamantayan sa pagsusuri ng droga, na nakabalangkas sa Welfare and Institutions Code Section 14105.39(c)(1) at (2):​​ 

• Ang kaligtasan ng gamot​​ 
• Ang pagiging epektibo ng gamot​​ 
• Ang mahahalagang pangangailangan para sa gamot​​ 
• Ang potensyal para sa maling paggamit ng gamot​​ 
• Ang halaga ng gamot sa programa​​ 

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. Mayroon bang anumang mga pagbabago sa batas na nauugnay sa 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.​​ 
• Inalis ang Medi-Cal fee-for-service na mga co-pay sa reseta.​​ 
• 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. Para sa mga gamot na nangangailangan ng paunang awtorisasyon (PA), kailangan bang magsumite ng PA ang mga nagrereseta o tagapagkaloob sa tuwing ibibigay ang isang gamot?​​ 

Hindi, maaaring sakupin ng PA ang maramihang mga pagpuno na ibinibigay sa loob ng naaprubahang tagal ng PA.​​ 

53. Nagsagawa ba ang DHCS ng mga pagbabago sa patakaran upang payagan ang mga pag-apruba ng multi-year priorization (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. Will the Department of Health Care Services (DHCS) consider making policy changes to allow for enhanced and/or expanded auto-adjudication functionalities?​​ 

As part of Medi-Cal Rx, DHCS continues to enhance and/or expand auto-adjudication functionalities (for example, automated claim approval and payment) to reduce the number of drugs with prior authorization (PA) requirements that require manual review.​​ 

55. Does Medi-Cal Rx include opioid management services?​​ 

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.​​ 

In addition, as part of Medi-Cal Rx, DHCS solicited proposals as part of the Request for Proposal (RFP) to further explore enhanced opioid management utilization management tools that go above and beyond what is required by federal law. Going forward, DHCS will consider implementing the enhanced opioid management services proposed.​​  

56. Magsasama ba ang Medi-Cal Rx ng programa sa pag-lock-in ng botika?​​ 

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. Saan ko mahahanap ang Medi-Cal Rx All Plan Letter para sa Medi-Cal Managed Care Plans (MCPs) na nagbibigay ng gabay mula sa isang patakaran at programmatic na pananaw?​​ 

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

58. Saan ko mahahanap ang Departamento ng Managed Health Care All Plan Letter, na nauugnay sa Medi-Cal Rx, para sa Medi-Cal Managed Care Plans (MCPs) na nagbibigay ng patnubay mula sa isang regulatory, compliance, at perspective ng pag-file?​​ 

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?​​ 

Ang IN 20-03 para sa CCS at GHPP Program kaugnay ng Medi-Cal Rx ay makukuha sa website ng DHCS .​​ 

60. Saan ko mahahanap ang Behavioral Health Informational Notice (BHIN) na nagbibigay ng patnubay na may kaugnayan sa Medi-Cal Rx para sa kalusugan ng isip ng county at mga serbisyo ng Substance Use Disorder (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.​​  

Paunang Awtorisasyon/ Pamamahala sa Paggamit​​ 

61. Sa ilalim ng Medi-Cal Rx, paano susuriin at hatulan ang mga kahilingan sa paunang awtorisasyon (PA)?​​ 

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. Are Medi-Cal Managed Care Plans (MCPs) be allowed to contract with the Medi-Cal Rx Contractor to perform prior authorization (PA)?​​ 

Hindi. Dahil ang mga Medi-Cal MCP ay hindi na mananagot ayon sa kontrata para sa benepisyo ng parmasya ng Medi-Cal pagkatapos ng buong Assumption of Operations ng Medi-Cal Rx sa Enero 1, 2022, ang lahat ng mga adjudication ng PA at mga kaugnay na proseso ay ibibigay ng MMA, naaayon sa mga kinakailangan sa kontrata at sa direksyon ng DHCS.​​ 

340B Federal Drug Discount Program​​ 

63. Ano ang pederal na 340B Program?​​ 

Ang Seksyon 340B ng Public Health Services Act (Title 42 United States Code Section 256b) ay nagtatatag ng pederal na programa na kilala bilang 340B Drug Pricing Program (340B Program), na nilikha noong 1992 pagkatapos ng pag-ampon ng Medicaid Drug Rebate Program. Ang Health Resources and Services Administration, isang ahensya sa ilalim ng United States Department of Health and Human Services, ay nangangasiwa at namamahala sa programa sa pamamagitan ng Office of Pharmacy Affairs nito.​​ 

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. Sino ang gumagamit ng 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. Ano ang pakikipag-ugnayan sa pagitan ng aming panukalang inireresetang gamot at ng 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.​​ 

In October 2009, California codified a pre-existing policy that requires 340B covered entities to dispense only 340B inventory to Medi-Cal members, and bill at their Actual Acquisition Cost (AAC) for those drugs when dispensed through the Medi-Cal fee-for-service delivery system, consistent with Welfare and Institutions Code (W&I Code), Section 14105.46. The 340B actual acquisition cost billing requirement only applies to the fee-for-service delivery system.​​ 

Sa sistema ng paghahatid ng pinamamahalaang pangangalaga, ang 340B na gamot na ibinibigay sa mga miyembro ng Medi-Cal ay hindi napapailalim sa mga kinakailangan sa pagsingil sa bayad-para-serbisyo sa pagkuha ng serbisyo. Nagbibigay-daan ito sa mga sakop na entity at Medi-Cal Managed Care Plans (MCPs) at/o mga kinontratang Pharmacy Benefit Managers (PBMs) na makipag-ayos sa mga pagsasaayos ng reimbursement na nagreresulta sa mas mataas na reimbursement sa 340B na sakop na entity sa sistema ng paghahatid ng pinamamahalaang pangangalaga kung ihahambing sa kung paano ire-reimburse ang mga entity na iyon sa sistema ng paghahatid ng Medi-service. Ang mga kita na ito ay hindi ibinabahagi sa estado, ni ang mga halaga ng naturang mga kita ay hindi alam ng estado.​​ 

Nagbibigay-daan ang Medi-Cal Rx para sa pagkakapareho ng patakaran at pinahusay na pangangasiwa ng mga paghahabol para sa mga gamot na ibinibigay at sinisingil sa pamamagitan ng 340B Program.​​ 

66. Does Medi-Cal Rx preclude a provider from continuing as a 340B entity?​​ 

Hindi. Bilang karagdagan, hindi binabago o inaalis ng panukala ang 340B Program sa California.​​ 

67. How is the Department of Health Care Services (DHCS addressing the concerns raised as to the effect of Medi-Cal Rx on the administration of the 340B Program?​​ 

Kinikilala ng DHCS ang mahalagang papel ng ating mga tagapagbigay ng safety net at ang kritikal na gawaing ginagawa nila para sa mga benepisyaryo ng Medi-Cal. Ang DHCS ay nagtrabaho at patuloy na nakikipagtulungan at nakikibahagi sa mga talakayan sa iba't ibang interesadong partido at stakeholder sa ngalan ng mga pasilidad at grupo ng pangangalagang pangkalusugan upang mas maunawaan ang epekto ng pagpapatupad ng Medi-Cal Rx sa kanilang 340B na Programa at mga kaugnay na proseso, gayundin upang higit pang talakayin ang mga potensyal na opsyon para sa pagpapagaan.​​ 

68. Paano ilalaan at/o gagawing available ng DHCS ang supplemental payment pool para sa mga non-hospital 340B na klinika?​​ 

Nagtipon ang DHCS ng isang stakeholder workgroup upang bumuo ng pamamaraan para sa pamamahagi ng mga pandagdag na bayad sa pool sa mga kwalipikadong non-hospital na 340B na mga klinika ng komunidad. Kasama sa mga paksa ng workgroup ang mga pamantayan sa pagiging karapat-dapat para sa pagtanggap ng mga pandagdag na pagbabayad, ang pinagsama-samang halaga ng pagpopondo sa pool na magagamit sa kani-kanilang taon ng pananalapi, at ang pamantayan para sa paghahati-hati ng pagpopondo ng pool sa mga kwalipikadong non-hospital na 340B na mga klinika ng komunidad kabilang ang tiyempo, dalas, at halaga ng mga resultang pandagdag na pagbabayad. Ang State Plan Amendment (SPA) ay naaprubahan. Bukod pa rito, ang isang notice na inilathala noong Hunyo 28, 2023, ay nagsasaad na ang DHCS ay magsasagawa ng mga karagdagang pagbabayad para sa mga kwalipikadong hindi ospital na 340B na pagbisita sa klinika ng komunidad para sa mga petsa ng serbisyo mula Hulyo 1, 2023 hanggang Disyembre 31, 2023, alinsunod sa mga probisyon ng Assembly Bill 80.​​ 

Mga Reklamo/ Karaingan ng Medi-Cal Rx Resolution at Mga Proseso ng Apela​​ 

69. Anong mga proseso ng paglutas ng mga reklamo at karaingan ang kailangan ng mga benepisyaryo ng Medi-Cal upang tugunan ang mga isyu sa benepisyo sa parmasya?​​ 

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. Anong mga reklamo at karaingan na nauugnay sa parmasya ang hahawakan sa pamamagitan ng Medi-Cal Rx?​​ 

Lahat ng mga reklamo at hinaing na may kaugnayan sa parmasya para sa mga serbisyong Medi-Cal Rx na ibinigay pagkatapos ng buong Assumption of Operations ng Medi-Cal Rx sa Enero 1, 2022, ay hahawakan sa pamamagitan ng Customer Service Center ng Medi‑Cal Rx para sa triaging, pananaliksik, at resolusyon. Para sa karagdagang impormasyon, pakitingnan ang Patakaran sa mga Reklamo at Karaingan ng Medi-Cal Rx ng DHCS.​​ 

71. How did the Department of Health Care Services (DHCS) address complaints and grievances that arose for pharmacy-related services provided by the Medi-Cal Managed Care Plans (MCPs) on or before Medi-Cal Rx full 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.​​ 

Ang mga reklamo at karaingan na nauugnay sa parmasya na natanggap pagkatapos ng Medi-Cal Rx full AOO ng Medi-Cal Rx Customer Service Center (CSC) para sa mga serbisyong ibinigay ng isang Medi-Cal MCP sa o bago ang Medi-Cal Rx full AOO ay ililipat ng Medi-Cal Rx CSC sa naaangkop na Medi-Cal MCP para sa buong resolusyon.​​ 

Ang Medi-Cal Rx CSC ay magpapayo sa mga miyembro ng Medi-Cal MCP na dapat nilang kontakin ang kanilang MCP para sa mga naturang reklamo at karaingan na nauugnay sa parmasya.​​ 

Ang karapatan ng mga miyembro ng Medi-Cal MCP na magsumite ng mga reklamo at karaingan sa kanilang mga Medi-Cal MCP para sa mga serbisyong nauugnay sa parmasya na ibinigay sa o bago ang buong AOO ng Medi-Cal Rx ay hindi naaapektuhan ng 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. Anong (mga) mekanismo ng apela ang kailangan ng mga benepisyaryo ng Medi-Cal upang tugunan ang mga isyu sa benepisyo sa parmasya?​​ 

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. Kung gusto ng isang benepisyaryo ng Medi-Cal ng State Fair Hearing, mayroon bang anumang limitasyon sa oras?​​ 

Oo, mayroon lamang 90 araw ang mga benepisyaryo ng Medi-Cal para humingi ng pagdinig, na naaayon sa naaangkop na batas ng estado.​​ 

75. Makukuha pa rin ba ng mga benepisyaryo ng Medi-Cal ang kanilang paggamot habang naghihintay ng desisyon ng State Fair Hearing?​​ 

Oo. Upang patuloy na matanggap ang mga serbisyo ng Medi-Cal Rx na ang abiso sa pagtanggi ay huminto at/o nagbabago, ang mga benepisyaryo ng Medi-Cal ay dapat humingi ng Pagdinig ng Estado sa loob ng sampung araw mula sa petsa ng NOA, o bago ang petsa, ang abiso ay nagsasabi na ang iyong paggamot ay hihinto o magbabago, alinman ang mas huli.​​ 

Kapag humihiling ng State Fair Hearing, dapat ipahiwatig ng mga benepisyaryo ng Medi-Cal na gusto nilang patuloy na makakuha ng mga serbisyo ng Medi-Cal Rx sa panahon ng proseso ng pagdinig. Pakitandaan na maaaring tumagal ng hanggang 90 araw para mapagpasyahan ang isang kaso at maipadala ang panghuling pagpapasiya sa benepisyaryo ng Medi-Cal.​​ 

76. Maaari bang humiling ang mga benepisyaryo ng Medi-Cal ng pinabilis na State Fair Hearing?​​ 

Oo. Maaaring humiling ang mga benepisyaryo ng Medi-Cal ng pinabilis na pagdinig sa pamamagitan ng pagsusumite ng sulat mula sa kanilang doktor na nagpapaliwanag kung paano maaaring maging peligroso sa kanilang buhay at/o kalusugan ang paghihintay ng hanggang 90 araw. Dapat ipadala ng mga benepisyaryo ng Medi-Cal ang sulat kasama ng kanilang kahilingan sa pagdinig. Para sa higit pang impormasyon tungkol sa proseso ng Pagdinig ng Estado, mangyaring bisitahin ang website ng Medi-Cal Fair Hearing ng DHCS.​​ 

77. Para sa mga apela ng Medi-Cal Rx na desisyon sa saklaw ng provider ng Medi-Cal at/o Managed Care Plan (MCP), lilikha ba ang DHCS ng hiwalay na proseso ng external na apela ng Medi-Cal Rx kung saan sinusuri ng mga independiyenteng medikal na eksperto ang mga desisyon?​​ 

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. Anong mga apela na nauugnay sa parmasya ang hahawakan sa pamamagitan ng Medi-Cal Rx?​​ 

All pharmacy-related appeals for Medi-Cal Rx services provided after the Medi‑Cal Rx full Assumption of Operations will be handled through Medi‑Cal Rx utilizing the existing State Fair Hearing process, administered through the California Department of Social Services, as described in questions #73-76 above.​​ 

79. How did the Department of Health Care Services (DHCS) address appeals from Medi-Cal Managed Care Plan (MCP) beneficiaries that arose for pharmacy-related services provided by the Medi-Cal MCPs on or before Medi-Cal Rx full Assumption of Operations (AOO)?​​ 

Dapat lutasin ng mga Medi-Cal MCP ang lahat ng apela ng benepisyaryo ng Medi-Cal MCP na nagmula bilang resulta ng isang desisyon ng MCP na may kaugnayan sa mga serbisyong nauugnay sa parmasya kung saan nasa panganib ang MCP noong o bago ang buong AOO ng Medi-Cal Rx. Ang karapatan ng mga miyembro ng Medi-Cal MCP na magsumite ng mga apela sa Department of Managed Health Care, kabilang ngunit hindi limitado sa karapatan sa Independent Medical Review, para sa mga serbisyong nauugnay sa parmasya na ibinigay ng Medi-Cal MCPs na ibinigay sa o bago ang buong AOO ng Medi-Cal Rx, ay hindi naaapektuhan ng Medi-Cal Rx.​​ 

Epekto sa Pananalapi/ Pagtatasa​​ 

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

Yes. DHCS completed a fiscal analysis for Medi-Cal Rx and shared this information publicly. DHCS anticipates approximately $309 million General Fund (GF) in annual savings by 2023-24. DHCS included the fiscal estimate for Medi-Cal Rx as part of the biannual Medi-Cal Estimate process, and will be providing necessary adjustments, if any, to the fiscal analysis on an ongoing basis moving forward.​​ 

81. Whatare the elements of our projected $309 million General Fund (GF) in annual savings by 2023-24?​​ 

Ang mga elemento ng inaasahang $309 milyong GF savings sa 2023-24 ay kasama ngunit hindi limitado sa mga sumusunod na salik:​​ 

• Mga karagdagang rebate ng karagdagang gamot ng estado na nagreresulta mula sa paglipat ng paggamit ng gamot mula sa sistema ng paghahatid ng pinamamahalaang pangangalaga patungo sa sistema ng paghahatid ng bayad para sa serbisyo.​​ 
• Pagpapatupad ng Maximum Allowable Ingredient Costs (MAICs) para sa mga gamot na may magagamit na tatlo (3) o higit pang mga opsyon na katumbas ng pangkalahatan.​​ 
• Pagbawas ng mga gastos na nauugnay sa mga administratibong tungkulin ng maramihang mga tagapamahala ng benepisyo ng parmasya na ginagamit ng iba't ibang Medi-Cal Managed Care Plans (MCPs).​​ 
• Medi-Cal fee-for-service reimbursement methodology, na kinabibilangan ng $10.05/$13.20 dispensing fees.​​ 
• Ang isang bagong karagdagang bayad para sa mga hindi ospital na 340B na klinika, na epektibo sa Medi-Cal Rx full Assumption of Operations noong Enero 1, 2022, ay kasama sa 2021-22 na badyet. Tingnan ang tanong #70 sa itaas para sa karagdagang impormasyon.​​ 

As noted in question #80 above, any adjustments to the Medi-Cal Rx fiscal estimate, inclusive of savings projections, will be updated as part of the biannual Medi-Cal Estimate process.​​ 

Miscellaneous/ Ibang Impormasyon​​ 

82. Does Medi-Cal Rx include mail-order pharmacy options?​​ 

Yes. Mail-order options are available in Medi-Cal through Medi-Cal Rx. If the pharmacy is an enrolled Medi-Cal pharmacy provider, the pharmacy may dispense the medication on-site or through a mail-order service. The Department of Health Care Services (DHCS) has ensured continuation of an effective mail-order service option for Medi-Cal pharmacy services.​​ 

83. Ginagawa bang pampubliko ng Department of Health Care Services (DHCS) ang mga kontrata sa karagdagang rebate ng gamot sa parmasya ng Medi-Cal?​​ 

Hindi. Parehong pinoprotektahan ng batas ng estado at pederal ang pagiging kumpidensyal ng mga karagdagang kontrata sa rebate ng gamot.​​ 

84. Is the Medi-Cal Rx Contractor required to contract with existing pharmacies in the current networks?​​ 

Hindi. Ang Magellan Medicaid Administration, LLC (MMA) ay hindi nakikipagkontrata sa anumang provider. Ang lahat ng aktibidad sa pagpapatala ng tagapagkaloob gayundin ang pagpapanatili ng network ng parmasya ng Medi-Cal ay pinananatili ng Department of Health Care Services (DHCS).​​ 

84. How many active, California-licensed pharmacies are enrolled in Medi-Cal fee-for-service?​​ 

Bawat Enero 2023, data ng Department of Health Care Services (DHCS), 6,547 na tagapagbigay ng parmasya na lisensyado ng California ang nakatala sa bayad-para-serbisyo ng Medi-Cal.​​ 

85. Does Medi-Cal engage in an effort to enroll the pharmacies that are part of Managed Care Plan (MCP) networks but not enrolled in Medi-Cal fee-for-service?​​ 

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. In what capacity will Medi-Cal Managed Care Plans (MCPs) and other entities be expected to participate in meetings for the Medi-Cal Global Drug Use Review (DUR) Board and other Department of Health Care Services (DHCS) driven pharmacy committees?​​ 

Sa kasalukuyan at patuloy na post-transition, inaasahan ng DHCS na ang mga Medi-Cal MCP nito at iba pang interesadong partido ay patuloy na lalahok sa mga pulong na nauugnay sa Medi-Cal Global DUR Board at sa iba pang komite ng parmasya na hinimok ng DHCS, kung kinakailangan. Bilang karagdagan, ang DHCS ay patuloy at aktibong sinusuri at tinatasa kung paano mas epektibong makisali at makipagtulungan sa mga Medi-Cal MCP at iba pang mga entity sa mga talakayan at desisyon na nauugnay sa patakaran sa parmasya ng Medi-Cal na sumusulong.​​ 

87.  Does the Department of Health Care Services (DHCS) have a subscription service for updates and news relative to 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.​​