Medi-Cal Rx
Pangkalahatang-ideya
On January 7, 2019, Governor Gavin Newsom issued Executive Order N-01-19 to achieve cost-savings for drug purchases made by the state. A key component of the order requires the DHCS to transition all Medi-Cal pharmacy services from managed care (MC) to fee-for-service (FFS).
Ang paglipat ng mga serbisyo ng parmasya mula sa MC patungo sa FFS 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 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”.
Ang iba pang mga pagbabago na nagreresulta mula sa paglipat sa FFS ay kinabibilangan ng:
- Ilapat ang mga protocol sa pamamahala ng paggamit sa buong estado sa lahat ng mga gamot sa outpatient.
- Strengthen California’s ability to negotiate state supplemental drug rebates with drug manufacturers.
Mga Mapagkukunan at Sanggunian na Materyales
Ang mga sumusunod ay mga mapagkukunan at sangguniang materyal para sa mga benepisyaryo at provider tungkol sa mga serbisyo ng Medi-Cal Rx:
- Medi-Cal Rx Claim Edits and Prior Authorization Reinstatement Plan: This is a phased approach for the reinstatement of claim edits and prior authorizations, and the phasing out of the Transition Policy. The June 2022 Medi-Cal Rx Reinstatement of Prior Authorizations and Retirement of the Transition Policy Phase I presentation, and the December 2022 Phases II, III, and IV presentation. The September 2023 Advancing Medi-Cal Rx presentation. For more information on the Medi-Cal RX Reinstatement, you can go to the Medi-Cal Rx Portal/ Education and Outreach Webpage.
- Medi-Cal Rx Conflict Avoidance Plan: Updated August 29, 2022. On July 27, 2021, DHCS accepted a Conflict Avoidance Plan submitted by its Medi-Cal Rx vendor, MMA, a subsidiary of Magellan Health, Inc. (Magellan), to mitigate conflicts associated with the proposed acquisition of Magellan by Centene Corporation.
- Medi-Cal Rx Website: Starting on January 1, 2021, the new Medi-Cal Rx site will be the place to go to access both public and secure Medi-Cal Rx portals. Starting on January 1, 2022, the secure portal will give pharmacy providers, prescribers and their staff access to the Prior Authorization (PA) system; beneficiary drug look-up tool; and web and batch claims submissions.
- Medi-Cal Rx Frequently Asked Questions (FAQs): Updated April 18, 2023, this document provides additional guidance and clarification to Medi-Cal beneficiaries, providers, plan partners, and other interested parties on COVID-19 over the counter (OTC) Self-Administered Antigen Tests. As DHCS receives additional questions, this document will be updated as indicated by the version number and date in the footer.
- Medi-Cal Rx Pharmacy Transition Policy: Updated April 7, 2021, this document describes DHCS’ multi-faceted pharmacy transition policy, inclusive of “grandfathering” previously approved PAs from managed care and fee-for-service, as well as a 180-day period with no PA requirements for existing prescriptions, that helped in supporting Medi-Cal Rx transition. During this transition period, Magellan provided system messaging, reporting and outreach to grant Medi-Cal Rx a smooth transition.
- Medi-Cal Rx PA/Utilization Management (UM) and Related Appeals Processes: Updated November 05, 2021 this document outlines DHCS’ FFS Medi-Cal PA/UM and related appeals processes, which align with and build upon existing Medi-Cal FFS processes and protocols for the Medi-Cal program more broadly. This update reflects the new Medi-Cal Rx implementation date and contains a revised Medi-Cal Fair Hearing stakeholder engagement timeline.
- Medi-Cal Rx Complaints and Grievances: Updated April 7, 2021, this document outlines DHCS’ FFS Medi-Cal Rx complaints and grievances policy, which aligns with and builds upon existing Medi-Cal FFS processes and protocols for the Medi-Cal program, more broadly.
- Medi-Cal Rx Website & Pharmacy Portal Policy:Updated July 19, 2023, this document offers information about DHCS’ dedicated Medi-Cal Rx website, which is now live and offers content available on a public platform that is accessible by all. Additionally, the Medi-Cal Rx website launched several different secure portals for the beneficiaries, providers (including physician prescribers and pharmacies), managed care plan (MCP) partners, and other entities as determined by DHCS, to ensure their access to the appropriate tools and resources for Medi-Cal Rx services that require access to protected health information.
- Medi-Cal Rx MCP Clinical Liaison Policy: Updated April 7, 2021, this document describes how Medi-Cal Rx will provide a dedicated Clinical Liaison (CL) team to support the Medi-Cal MCPs in their clinical obligations relating to beneficiary care coordination, medication adherence, and other responsibilities related to medication requirements. The Medi-Cal MCPs will be provided access to the MCP CL’s through Medi-Cal Rx’s dedicated Integrated Voice Response system to assist and resolve clinical pharmacy-related issues, as outlined in this document.
- Medi-Cal Rx Scope: Updated October 1, 2024, this document provides additional context and information related to the Department’s implementation of the Medi-Cal MC to FFS pharmacy carve out, effective January 1, 2022. It also provides an inventory of the Medi-Cal pharmacy benefit, characterized as either not subject to the carve out (i.e., those pharmacy benefits that are billed on medical and institutional claims), versus those subject to the carve out (i.e., all pharmacy benefits that are billed on pharmacy claims).
Pakikipag-ugnayan sa Stakeholder
Bilang bahagi ng paglipat na ito, ang DHCS ay nakatuon sa pakikipagtulungan sa mga panlabas na kasosyo nito (kabilang ang ngunit hindi limitado sa, MCP, Counties, Provider, Consumer Advocates, at Beneficiaries) upang matiyak ang maayos at matagumpay na paglipat sa pamamagitan ng mga sumusunod:
- Pampubliko na naglalabas ng mga materyales na nagbibigay-alam sa draft (tulad ng Kahilingan para sa Panukala, mga abiso ng provider at benepisyaryo, Lahat ng Liham ng Plano, atbp.) para sa komento.
- Pagtitiyak na ang mga MCP, Countie, provider, consumer advocate, at benepisyaryo ay makakatanggap ng napapanahon at tumpak na impormasyon na may kaugnayan sa paglipat at mga nauugnay na aktibidad sa pagpapatupad.
- Pagbibigay ng mga update sa status at pangangalap ng feedback ng stakeholder sa pamamagitan ng iba't ibang pampublikong pagpupulong na inisponsor ng DHCS.
Tandaan: Bilang karagdagan sa mga stand-alone na pagpupulong, hahanapin ng DHCS na gamitin ang mga kasalukuyang pagpupulong at workgroup (hal. stakeholder advisory committee, consumer stakeholder focus workgroup, Medi-Cal Medical Director's meeting) para magbigay ng mga update sa status sa mga pagsusumikap sa pagpapatupad at mga aktibidad na nauugnay sa Medi-Cal Rx.
Para sa mga indibidwal na may mga kapansanan, ang Departamento ay magkakaloob ng mga pantulong na kagamitan tulad ng sign-language na interpretasyon, real-time na captioning, mga tagakuha ng tala, tulong sa pagbabasa o pagsulat at pag-convert ng mga materyales sa pagsasanay o pagpupulong sa Braille, malaking print, audiocassette, o computer disk. Upang humiling ng mga naturang serbisyo o mga kopya sa isang kahaliling format, mangyaring tumawag o sumulat:
Lori Bradley, RPh
Department of Health Care Services
Pharmacy Benefits Division, MS 4604
Sacramento, CA 95814
Phone Number: (916) 552-9500
Email: medi-cal.pharmacybenefits@dhcs.ca.gov
Pakitandaan, ang hanay ng mga serbisyong pantulong na magagamit ay maaaring limitado kung ang mga kahilingan ay natanggap nang wala pang sampung araw ng trabaho bago ang pulong o kaganapan.
Medi-Cal Rx Advisory Workgroup
The Medi-Cal Rx Advisory Workgroup will meet three times between August 2021 and January 1, 2022 Assumption of Operations to help facilitate and further inform DHCS’ ongoing Medi-Cal Rx implementation efforts. Each Medi-Cal Rx Advisory Workgroup meeting will be held in Sacramento for approximately four hours. The Medi-Cal Rx Advisory Workgroup membership will be limited to 30 members to ensure a productive discussion environment. The Medi-Cal Rx Advisory Workgroup to be comprised of organizations and entities such as hospitals, clinics, health plans, counties, pharmacies, tribal health programs, consumer advocates and others. During the meetings, DHCS will provide updates on the pharmacy transition and request the Medi-Cal Rx Advisory Workgroup provide dialogue and input key topics, such as:
- Mga tungkulin at responsibilidad ng DHCS, ang Medi-Cal Rx Contractor, at Medi-Cal Managed Care Plans
- DHCS’ implementation strategies, tools, and timelines, including but not limited to, provider education and outreach and beneficiary notifications
- Pagbuo ng patakaran sa parmasya ng Medi-Cal, na isasama ang saklaw ng pag-ukit, paunang awtorisasyon, at mga protocol sa pamamahala ng paggamit
- Mga pagbabago sa mga kasalukuyang komite ng parmasya ng Medi-Cal
Pagkatapos ng paglipat, ang mga pagpupulong ng Medi-Cal Rx Advisory Workgroup ay tututuon sa pangangalap ng impormasyon, mga karanasan at/o feedback mula sa mga miyembro ng workgroup upang makatulong na pinuhin ang mga proseso at patakaran ng Medi-Cal Rx sa patuloy na batayan. Ang mga pagpupulong ay bukas sa publiko, at ang personal na komento sa publiko ay tatanggapin sa huling 30 minuto ng bawat pulong. Ang mga karagdagang detalye, kabilang ngunit hindi limitado sa impormasyon sa pag-check-in at paradahan, ay ipo-post kasama ang agenda nang hindi bababa sa 10 araw bago ang bawat pulong.
Iskedyul ng pulong ng Medi-Cal Rx Advisory Workgroup
Meeting #1: Enero 14, 2020 (Martes)
Meeting #2: Marso 18, 2020 (Miyerkules)
Meeting #3: Mayo 26, 2020 (Martes)
Pagpupulong #4: Hulyo 29, 2020 (Miyerkules)
Pagpupulong #5: Oktubre 21, 2020 (Miyerkules)
Pagpupulong #6: Enero 25, 2021 (Lunes)
Pagpupulong #7: Setyembre 13, 2021 (Lunes)
Meeting #8: Nobyembre 8, 2021 (Lunes)
Meeting #9: Enero 10, 2022 (Lunes)
Meeting #10: Marso 14, 2022 (Lunes)
Pagpupulong #11: Hunyo 2, 2022 (Huwebes)
Pampublikong Forum ng Medi-Cal Rx
Simula sa Hulyo 2019 at magpapatuloy sa buong taon ng kalendaryo 2020, ang DHCS ay nagho-host at magpapatuloy na magho-host ng isang (1) oras na Medi-Cal Rx Public Forum nang personal at sa pamamagitan ng webinar upang magbigay ng mga update sa katayuan upang makatulong na matiyak na ang mas malawak na komunidad ng stakeholder ay mapapanatili. up-to-date tungkol sa mga aktibidad at timeline ng pagpapatupad ng Medi-Cal Rx. Ang lahat ng petsa at oras ng pagpupulong ng Medi-Cal Rx Public Forum ay nakalista sa ibaba. Ang lahat ng mga interesadong organisasyon at entity, kabilang ang ngunit hindi limitado sa, mga ospital, klinika, Planong Pangkalusugan, mga county, parmasya, Tribal health Programa, at consumer advocates, ay iniimbitahan na lumahok.
Iskedyul ng Pampublikong Forum ng Medi-Cal Rx
Meeting #1: Hulyo 24, 2019 (Miyerkules)
Meeting #2: Setyembre 26, 2019 (Huwebes)
Meeting #3: Pebrero 20, 2020 (Huwebes)
Meeting #4 : Hunyo 17, 2020 (Miyerkules)
Meeting #5: Setyembre 22, 2020 (Martes)
Meeting #6: Disyembre 9, 2020 (Miyerkules)
Meeting #7: Setyembre 15, 2021 (Miyerkules)
Meeting #8: Nobyembre 10, 2021 (Miyerkules)
Meeting #9: Enero 12, 2022 (Miyerkules)
Meeting #10: Marso 16, 2022 (Miyerkules)
Meeting #11: Mayo 11, 2022 (Miyerkules)
Maglalabas ang DHCS ng karagdagang impormasyon pati na rin ang mga paalala sa pamamagitan ng iba't ibang listahan ng email na pamamahagi ng stakeholder ng DHCS. Bilang karagdagan, magpo-post din ang DHCS ng panghuling agenda nang hindi bababa sa 10 araw bago ang bawat pagpupulong.
Medi-Cal Rx: Mga Archive
All archived material from this page.
Makipag-ugnayan sa amin
For general questions relating to Medi-Cal Rx, please direct your comments and questions to medi-cal.pharmacybenefits@dhcs.ca.gov.