医疗补助计划
概述
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).
将药房服务从 MC 过渡到 FFS 将会实现以下目标：
- 在统一的配送系统下，实现全州范围内 Medi-Cal 药房福利的标准化。
- 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”.
向FFS过渡带来的其他变化包括：
- 将全州范围的利用管理协议应用于所有门诊药物。
- Strengthen California’s ability to negotiate state supplemental drug rebates with drug manufacturers.
资源和参考资料
以下是有关 Medi-Cal Rx 服务的受益人和提供者的资源和参考资料：
- 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).
利益相关方参与
作为此次过渡的一部分，DHCS 致力于与其外部合作伙伴（包括但不限于 MCP、县、提供商、消费者权益保护者和受益人）合作，通过以下方式确保顺利、成功地过渡：
- 公开发布草案通知材料（例如，提案请求书、提供者和受益人通知、所有计划信函等）以供评论。
- 确保 MCP、县、供应商、消费者权益保护者和受益人及时准确地收到与过渡和相关实施活动相关的信息。
- 通过 DHCS 赞助的各种公开会议提供状态更新并收集利益相关者的反馈。
注意：除了独立会议外，DHCS 还将寻求利用现有的会议和工作组（例如利益相关者咨询委员会、消费者利益相关者焦点工作组、Medi-Cal 医疗主任会议）提供与 Medi-Cal Rx 相关的实施工作和活动的最新状态更新。
对于残疾人士，该部门将提供辅助设备，如手语翻译、实时字幕、笔记记录器、阅读或写作辅助以及将培训或会议材料转换为盲文、大字印刷本、录音带或计算机磁盘。要请求此类服务或其他格式的副本，请致电或写信至：
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
请注意，如果在会议或活动前不到十个工作日收到请求，可用的辅助服务范围可能会受到限制。
Medi-Cal Rx 咨询工作组
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:
- DHCS、Medi-Cal Rx 承包商和 Medi-Cal 管理式医疗计划的角色和职责
- DHCS’ implementation strategies, tools, and timelines, including but not limited to, provider education and outreach and beneficiary notifications
- Medi-Cal 药房政策制定，包括豁免范围、事先授权和使用管理协议
- 现有 Medi-Cal 药房委员会的变更
过渡后，Medi-Cal Rx 咨询工作组会议将专注于收集工作组成员的信息、经验和/或反馈，以帮助持续完善 Medi-Cal Rx 流程和政策。 会议将向公众开放，每次会议的最后 30 分钟将接受公众的现场评论。 其他详细信息（包括但不限于登记入住和停车信息）将在每次会议召开前至少 10 天与议程一起发布。
Medi-Cal Rx 咨询工作组会议安排
第一次会议：2020 年 1 月 14 日（星期二）
第二次会议：2020 年 3 月 18 日（星期三）
第三次会议：2020 年 5 月 26 日（星期二）
会议 #4：7 月29日、 2020 （星期三）
会议 #5：10 月21日、 2020 （星期三）
会议 #6：1 月25日， 2021 （星期一）
会议 #7：9 月13日， 2021 （星期一）
第 8 次会议：2021 年 11 月 8 日（星期一）
第 9 次会议：2022 年 1 月 10 日（星期一）
会议 #10：2022 年 3 月 14 日（星期一）
会议 #11：6 月2日， 2022 （星期四）
Medi-Cal Rx 公共论坛
从 2019 年 7 月开始并持续到 2020 年，DHCS 已主办并将继续通过现场和网络研讨会形式主办一 (1) 小时的 Medi-Cal Rx 公共论坛，以提供状态更新，帮助确保更广泛的利益相关者社区及时了解 Medi-Cal Rx 实施活动和时间表。 所有 Medi-Cal Rx 公共论坛会议日期和时间均列示如下。 欢迎所有感兴趣的组织和实体参加，包括但不限于医院、诊所、健康计划、县、药房、部落健康计划和消费者权益倡导者。
Medi-Cal Rx 公共论坛日程安排
第一次会议：2019 年 7 月 24 日（星期三）
第二次会议：2019 年 9 月 26 日（星期四）
第三次会议：2020 年 2 月 20 日（星期四）
会议＃4：2020 年 6 月 17 日（星期三）
会议＃5：2020 年 9 月 22 日（星期二）
第 6 次会议：2020 年 12 月 9 日（星期三）
会议 #7：2021 年 9 月 15 日（星期三）
第 8 次会议：2021 年 11 月 10 日（星期三）
第 9 次会议：2022 年 1 月 12 日（星期三）
会议 #10：2022 年 3 月 16 日（星期三）
会议 #11：2022 年 5 月 11 日（星期三）
DHCS 将通过各种 DHCS 利益相关者电子邮件分发列表发布更多信息以及提醒通知。 此外，DHCS 还将在每次会议召开前至少 10 天发布最终议程。
Medi-Cal Rx：档案
All archived material from this page.
联系我们
For general questions relating to Medi-Cal Rx, please direct your comments and questions to medi-cal.pharmacybenefits@dhcs.ca.gov.