梅迪卡爾 Rx 常見問題
Medi-Cal Rx：將 Medi-Cal 藥房服務從託管護理轉換為服務收費常見問題
版本 16.0
八月 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.
目錄
一般資訊
採購資訊
轉換資訊
數據摘要, 電子訪問, & 其他臨床支持
提供者外展, 教育, & 培訓
受益人客戶服務 & 相關支持
受益人資格，費用分擔，& 其他健康保障相關問題
Medi-Cal 服務收費補償方法
政策考量
預先授權 ／ 使用率管理
340B 聯邦藥品折扣計劃
Medi-Cal Rx 投訴 ／ 異議解決方案 & 上訴程序
財政影響 ／ 評估
其他/其他資料
一般資訊
1.為什麼醫療保健服務部（DHCS）將 Medi-Cal 藥房受益從 Medi-Cal 託管服務提供系統轉換為服務費遞送系統？
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.
二.什麼是中卡 Rx？
Medi-Cal Rx 是醫療保健服務部（DHCS）給予 Magellan Medicaid 管理局有限責任公司（MMA）通過服務收費提供系統管理的集體藥房福利和服務的名稱，在完全承擔運作（AOO）。
三.完整的 Medi-Cal Rx 操作假設（AOO）代表什麼？
Medi-Cal Rx AOO 代表麥哲倫 Medicaid 管理局有限責任（MMA）對支持 Medi-Cal Rx 所需的所有剩餘行政服務承擔營運責任的日期，包括但不限於索賠管理，事先授權（PA）和使用率管理（UM），提供商和會員支持服務以及其他附屬和報告服務。 正如 #23 -25 問題所述，Medi-Cal Rx 完整 AOO 在 1 月 1 2022 舉行。 有關更多詳細信息，請參閱問題 #28 -30。
4.將 Medi-Cal 藥房福利從管理護理轉換為服務費用有什麼好處？
將藥房服務從 Medi-Cal 管理的護理轉換為服務費，其他事項包括：
- 在一個交付系統下，在全州範圍內標準化加州醫療補助健康保健計劃藥房福利。
- 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.
- 根據適當的情況，將全州使用管理（UM）協議套用到所有門診藥物。
- 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.DHCS 是否需要求聯邦批准才能實施 Medi-Cal Rx？
是的DHCS 已要求聯邦醫療保險和醫療補助服務中心（CMS）批准，以通過 CalAIM Section 1915（b）更輕鬆的應用程序將藥房福利從託管照護提供系統轉換為服務費。 豁免申請反映了藥房就藥房索償（包括受保門診藥物和醫生服用藥物）收取的藥房福利，如《 Medi-Cal Rx 全方案信函》（APL20-020）（ ） 生效1 2022。
六.哪些 Medi-Cal 託管護理計劃（MCP）受到 Medi-Cal Rx 的影響？
所有 Medi-Cal MCP，包括艾滋病醫療保健基金會都受到影響。 Medi-Cal Rx 不適用於長者全包護理計劃（PACE）計劃、長者護理行動網絡（SCAN）或主要風險醫療保險計劃（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 同時適用於 CCS 和 GHPP。 由於 Medi-Cal Rx 完全承擔運作（AOO），所有提前授權（PA）（分別為獨立和受養縣，以及僅 CCS、GHPP 和 CCS/GHPP Medi-Cal 成員）通過 Medi-Cal Rx 處理藥房索償計費的藥房福利。
正如下問題 #24 所述，DHCS 維持所有藥物保障和保單責任，並設定了與 PA 審判相關的所有標準。 此外，DHCS 認識到 CCS/GHPP 人群的專業醫療保健需求，繼續與 CCS 諮詢小組和該領域的其他關鍵利害關係人密切合作。
八.作為 Medi-Cal Rx 的一部分，什麼不會改變？
Medi-Cal Rx 沒有更改以下內容：
- The scope of the existing Medi-Cal pharmacy benefit.
- 在住院或長期護理（LTC）環境中（包括技術護理設施 [SNF] 和其他中間護理設施 [ICF]）中，無論送遞系統如何，都可以作為包裝/全包計費結構的一部分提供藥房服務。
- 現有的 Medi-Cal 管理醫療藥房分配（例如血因子、艾滋病毒/艾滋病藥物、抗精神病藥或用於治療物質使用障礙的藥物）。
- 以醫療和/或機構索償而不是藥房索償計費的任何藥房服務。
- 根據適用的加利福尼亞州法律定義的州公平聆訊（SFH）程序。
九.Medi-Cal Rx 如何影響住院或長期護理（LTC）中提供的藥物的支付？
正如問題 #8 中所述，如果藥物作為由 LTC/技術護理設施（SNF）提供的服務的一部分提供的一部分，則醫藥管理護理計劃（MCP）將繼續由 Medi-Cal 管理護理計劃（MCP）承擔責任。 否則，如果處方藥物不屬於 LTC/SNF 提供服務的綜合費率的一部分，而是按服務費計費，那麼這些藥物的財務責任由其收費的索償類型決定。 如果藥物由藥房發放並根據藥房索償計費，那麼它們將由 Medi-Cal Rx 編製並支付。 如果藥物由 LTC/SNF 提供，並根據醫療/機構索償付費用，則 MCP 負責，或加州醫療補助管理信息系統 (CA-MMIS) 財政中介人（如果會員為服務費）負責。
10. What pharmacy benefits will be “carved out” of Medi-Cal managed care due to Medi-Cal Rx?
Medi-Cal Rx 已承擔 Medi-Cal 託管護理計劃 (MCP) 的責任，在藥房索償向藥房索償收費時管理以下事項：
- 保障門診藥物，包括某些醫生服用藥物（PAD）
- 特定醫療用品
- 腸胃營養產品
不論索償類型 (即藥房或醫療索償)，服務中包含的藥物（例如血液因子、艾滋病毒/艾滋病藥物、抗精神病藥物或用於治療物質使用障礙的藥物），都不論索償類型如何 (即藥房或醫療索償)。 這些藥物類別的醫療索賠應繼續作為服務費索償向 Medi-Cal 財政中介機構 (FI) 提交。 提醒醫療提供者，未列在藥房合同藥物清單 (CDL) 中並由
非藥劑型醫療保健專業人員管理的藥物，通常應由管理提供者視為醫療索償，而不是由藥房計費。
新增非資本藥物分類清單的新增，通常需要至少 60 天才能成功支付索償。 要求提供商保留他們的索償，直到系統準備接受。
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).
十一.在 Medi-Cal Rx 完全假設操作 (AOO) 後，DHCS 將如何處理糖尿病用品的覆蓋範圍，包括測試棒、槍支、血糖計、控制解決方案和噴射裝置？
在 Medi-Cal Rx 下，糖尿病檢測試紙（用於尿液、血糖和酮類）和針頭的福利政策沒有變更，並受合約產品清單以及目前在 Medi-Cal 提供者手冊中的 醫療用品 部分發布的標準約束。
這些信息可在 Medi-Cal Rx 提供者手冊和 Medi-C al Rx 網站中找到。
特定的血糖計、控制解決方案和鎖定裝置是 Medi-Cal Rx 的藥房計費醫療保障，並且僅限於新創建的保障自我監測血糖系統（血糖計）清單、控制解決方案和鎖定裝置（可在 Medi-Cal Rx 網站上門戶提供）中的產品，以作為藥房保障考慮 Medi-Cal R 保障。1 2022此類別中不在此清單中的適用產品被視為不符合 Medi-Cal Rx 的保險考慮作為藥房福利。
未在保障自我監測血糖系統（血糖計）、控制解決方案和鎖定裝置清單中的非合約產品，可透過 Medi-Cal 管理護理計劃 (MCP) 或服務費財政中介 (FI) 賠償，作為醫療索償時獲 HCPC 計費的耐用醫療設備 (DME) 保障。 數量限制保持不變。
十二.DHCS 目前如何處理一次性外部門診胰島素輸送系統（Omnipod 和 V-Go）的覆蓋範圍，自 Medi-Cal Rx 完整操作假設（AOO）以來，這是否發生了變化？
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.
DIDD 需要事先授權（PA）才能獲得退款，並適用特定的保障標準。 DIDD 包含在過渡原則中。 對於先前以 CMS-1500 表格計算的醫療保障支付的索償，提交所需產品的藥房索償時，提交醫療保障申請時，提交醫療保障申請時，應包括先前提交醫療保障申請的有效保障和繼續治療的書面證明，以確保符合保障要求。
十三.在 Medi-Cal Rx 完全承擔操作後，DHCS 如何處理連續血糖監測器（CGM）、其他耐用醫療設備（DME）、DME 用品和一次性醫療用品的覆蓋範圍？
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.
對於服務費（FFS）Medi-Cal 受益人，從 1 月 2022 開始，先前以 CMS 1500 表格計算的醫療保障所支付的索償，必須作為藥房索賠提交給 Medi-Cal Rx。 這些 HCPCS 代碼將拒絕提交的醫療索賠，並在 12 月 1, 2022 之後提交的服務日期。
注意：部分 CGM 裝置的相應胰島素泵將繼續以 CMS 1500 表格透過 HCPCS 代碼計費的醫療保障計費的 DME。 有關 DME 胰島素泵和配件的保障和帳單信息，請參閱 Medi-Cal 藥房提供商手冊中的 DME 部分，請參閱 Medi-Cal 提供商網站上的 DME 部分。
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.
十四.在 Medi-Cal Rx 完全承受操作（AOO）後，DHCS 將如何處理目前或之前為醫療索償的其他醫療用品福利，以 HCPCS 代碼和 CMS-1500 表格計算？
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.
十五.Medi-Cal Rx 是否包括醫療和/或機構索償計費的藥房福利？
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.
十七.Medi-Cal 將如何為服務提供者提供 COVID-19 疫苗的補償？
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.
採購資訊
二十.醫療保健服務部如何管理 Medi-Cal Rx？
DHCS 於 2019 年 8 月 22 日發布提案申請 #19 -96125，以尋求一名行政服務承包商，為當時超過 1300 萬名 Medi-Cal 成員管理 Medi-Cal 服務費藥房服務。 2019 年 12 月 13 日，DHCS 向麥哲倫 Medicaid Administration, LLC 簽訂合同，根據 DHCS 指示提供全面的行政服務，包括但不限於索賠管理、事先授權（PA）和使用管理（UM）、藥房藥物回贈管理、提供者和會員支持服務以及其他輔助和報告服務以支持 Medi-Cal 藥房福利的管理。
二十一. 什麼是 Medi-Cal Rx 採購時間表？
Medi-Cal Rx 採購相關工作的時間表如下：
- 2019 年 7 月 22 日：在兩週的公開評論期間發布中醫藥 Rx 提案請求（RFP）#19 -96125 草案。
- 2019 年 8 月 22 日：最終醫療卡 Rx 報告 #19 -96125 發布。
- 2019 年 8 月 29 日：醫療保健服務部（DHCS）的最終醫療卡 Rx RFP #19 -96125 問題。
- 2019 年 9 月 17 日：已發布與最終醫療卡 Rx Rx RFP #19 -96125 相關問題的答案和附錄。
- 2019 年 10 月 1 日：所有醫療卡 Rx RFP #19 -96125 提案到期。
- 2019 年 11 月 7 日：有關頒獎意向公告張貼到 DHCS 網站。
- 2019 年 12 月 13 日：DHCS 向麥哲倫醫療補助管理局有限責任公司（MMA）授予合同。
- 二零一九年十二月二十日：合約生效日期。
- January 1, 2022: Medi-Cal Rx Full Assumption of Operations (AOO) took place.
二十二.誰是通過採購流程選擇的 Medi-Cal Rx 承包商？
選擇管理 Medi-Cal 服務費藥房服務的 Medi-Cal Rx 承包商是麥哲倫醫療補助管理局有限責任公司（MMA）。
23. What roles and responsibilities will Medi-Cal Managed Care Plans (MCPs) maintaining upon Medi-Cal Rx’s full Assumption of Operations (AOO)?
Medi-Cal MCP 將負責包括但不限於以下活動：
- 監督和維護所有註冊 Medi-Cal 會員護理協調和相關活動所需的活動，並符合合同義務。
- 對藥房遵守的所有臨床方面提供監督和管理，包括提供疾病和藥物管理。
- 處理和支付所有醫療和機構索償計費的藥房服務。
- 參與與 Medi-Cal 全球藥物使用檢討（DUR）委員會和其他醫療保健服務部（DHCS）驅動的藥房委員會會議有關的會議。
- 持續和持續參與索償後審判 DUR 活動，例如回顧 DUR（RetroDur）（視乎照護協調需要）、教育計劃以及提交 DUR 年報。
24. What roles and responsibilities will DHCS maintain upon Medi-Cal Rx’s full Assumption of Operations?
DHCS 將負責包括但不限於以下活動：
- 制定、實施和維護所有 Medi-Cal 藥房政策，包括但不限於：
- 藥物保障
- 國家補充藥物回贈
- 事先授權（PA）/使用率管理（UM）
- 協商和簽訂國家補充藥物回贈。
- 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).
- 為州公平聽證會（SFH）程序提供監督和促進。
- 建立 Medi-Cal Rx 藥房補償方法，符合適用的州和聯邦要求。
- 建立和維護 Medi-Cal 藥房供應商網絡。
- 與麥哲倫醫療補助管理局有限責任公司（MMA）合作監督 Medi-Cal 全球藥物使用審查（DUR）委員會和其他部門驅動的藥房委員會。
- 合同管理和綜合格鬥的監督/監控。
25. What roles and responsibilities will the Medi-Cal Rx Contractor assume upon Medi-Cal Rx’s full Assumption of Operations?
麥哲倫醫療補助管理局有限責任（MMA）將負責包括但不限於以下活動：
- 提供 Medi-Cal Rx 客戶服務中心 (CSC)，每週 7 天，每年 365 天提供，不包括批准的假期，或者除非衛生護理服務部（DHCS）另有指示外，以支持所有提供者和會員電話，以支持所有提供者和會員的電話，以及提供外展、培訓和通知材料。
- 提供直接的 Medi-Cal 託管護理計劃（MCP）聯繫人，以協助治療協調和臨床問題。
- 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.
- 為所有藥房索償收費的藥房服務提供索賠管理、處理和付款功能。
- 監督福利（COB）與其他健康保障（包括聯邦醫療保險）的協調。
- 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. - 提供前瞻性和回顧藥物使用檢討（DUR）服務。
- 為 Medi-Cal MCP 提供數據摘要（至少每天），以支持他們在會員護理協調、執行藥房遵守臨床方面以及疾病和藥物管理的責任。
- 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.
二十六. 衞生護理署如何確保 Medi-Cal Rx 承辦商不會將病人資料（包括處方資料）用於 Medi-Cal Rx 行政服務以外的任何目的？
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.
二十七. 我在哪裡可以找到有關 Medi-Cal Rx 提案請求 #19 -96125 的更多信息？
如需更多有關醫用卡 Rx 申請提案 #19 -96125 的資訊，請瀏覽菲 $ 卡爾/加州電子採購網站。 最終提案將於台灣時間台灣時間 1，2019 晚上四點之前截止。 採購程序現已關閉。
轉換資訊
二十八. Medi-Cal Rx 全面操作假設（AOO）何時進行？
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. Why was the planned Go-Live date of April 1, 2021 for Medi-Cal Rx’s full Assumption of Operations delayed?
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.
2021 年 1 月，森騰公司宣布計劃收購麥哲倫。 Centene 透過子公司經營管理護理計劃 (MCP) 和參與 Medi-Cal 的藥房。 此交易非常意外，需要額外的時間來探索可接受的避免衝突協議，以確保公司實體之間有可接受的防火牆，以保護所有 Medi-Cal 成員的藥房索償數據，並保護其他專有信息。
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:
- 允許 Medi-Cal 提供商、託管護理計劃（MCP）和其他有關人士註冊 Medi-Cal Rx 安全入口網站並參加全面的培訓，從而確保對項目的更全面了解，並支持供應商和 MCP 的營運準備。
- 站起來，動員 Medi-Cal Rx 客戶服務中心 (CSC)，讓 CSC 的專家能夠在 Medi-Cal 成員、提供商、MCP 和其他有關人士的問題進行現場並回答，在 Medi-Cal Rx 完全實施後，可能預防混亂和其他潛在挑戰。 雖然 CSC 專家在 AOO 之前並沒有提供完整的服務，但他們追求
Medi-Cal Rx 全面 AOO。 他們能夠提供重要的 TSS，包括與 Medi-Cal Rx 工具和功能有關的主動外展，以及針對性的幫助和關鍵信息。 - 為 MCP 提供額外的時間與專門的 Medi-Cal Rx 臨床聯絡人互動並建立關係，他們幫助 MMA 建立準確和全面的 MCP 檔案，以確保持每個 MCP 服務的人群的個性化需求。
- 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.
在 Medi-Cal Rx 完成 AOO 後，MMA 承擔支持 Medi-Cal Rx 所需的所有其餘行政服務，包括但不限於以下事項：
- 將 CSC 工作時間延長至每週 7 天，每年 365 天，不包括批准的假期，或除非 DHCS 另有指示，否則以支持所有提供商和會員的電話，以及外展、培訓和通知材料。
- 索償管理、事先授權 (PA) 和使用率管理 (UM)、供應商和會員支援服務，以及其他附屬和報告服務。
有關更多詳細信息，請參閱問題 #23 -25。
三十一. DHCS 如何確保在過渡過程中利用 Medi-Cal 託管護理計劃（MCP）和其他利害關係人的知識和經驗，以實現服務的成功連續性？
DHCS 通過多種方式和多種途徑主動與外部合作夥伴聯繫，以確保利用知識和經驗來使 Medi-Cal Rx 成功。 DHCS 打算繼續這些類型的參與工作，並致力與其外部合作夥伴合作，包括 Medi-Cal MCP，縣，提供商，消費者倡導者和受益人，以確保流暢和成功的過渡。 例如，DHCS 已經成立了一個專門的 Medi-Cal MCP 工作小組和一個由各種利益相關者代表組成的 Medi-Cal Rx 諮詢工作小組，他們定期會面，討論各種問題、確定最佳做法，並提供可行的解決方案和策略以支持 DHCS 的實施工作。
未來，DHCS 還將繼續積極探索簡化和增強 Medi-Cal 周圍的現有利益相關者參與和外展工作的機會，其中將包括針對性的 Medi-Cal Rx 工作小組會議和討論，以合作，以滿足所有受影響方的需求的最佳實踐和實施策略。
三十二.如何傳達有關 Medi-Cal Rx 轉換和其他相關變更的信息？
DHCS 將與 MMA 合作，確保所有有關人士（包括但不限於 Medi-Cal MCP，心理健康計劃，藥物使用障礙計劃，提供者和受益人）獲得了通知過渡和其他相關更改。
通訊將通過多種方式傳播，包括但不限於以下方式：
- 新的 Medi-Cal Rx 網站於 2020 年 6 月推出，可作為教育和向有關人士傳達可用資源，信息和更改的平台。 經常發布和更新教育內容和常見問題。
- 從 2020 年 6 月開始，Medi-Cal Rx 網站提供了 Medi-Cal Rx 訂閱服務（MCRXSS），讓有關人士可以通過電子郵件註冊並定期接收 Medi-Cal Rx 更新。
- 從 2020 年 8 月起，有興趣人士可以查看 Medi-Cal Rx 網站門戶上發布的有關更改的公告。
- 新的 Medi-Cal Rx 網站提供了一系列為 Medi-Cal 提供者和 MCP 提供的培訓和教育材料。 自 2020 年 9 月起，MCP 和提供者已能夠註冊培訓和教育活動。
- 通知中心及服務交付費系統中的通知已於十月 1、2020、十一月 1、2020 及十二月 15 2020 或左右寄送給中醫服務受益人的通知。 由 2021 年 3 月底開始發送給 Medi-Cal 受益人的通知，通知他們有關延遲到 Medi-Cal Rx 全面承擔營運（AOO）。 附加通知已於 11 月 1, 2021 或左右郵寄給 Medi-Cal 受益人，並於 1 月 1, 2022 公布 AOO。
- 一項 Medi-Cal MCP Medi-Cal Rx 外展活動，通過傳統的外地呼叫活動或其他替代通訊方式（經 DHCS 批准）進行，向註冊會員進行。
- Medi-Cal 管理護理計劃成員手冊（保障證據）的更新，以及其他受影響實體的通知材料。
- 根據 DHCS 指導，更新 Medi-Cal 提供者手冊，以及 MMA 發布的新提供者指導和材料。
- 根據需要更新 Medi-Cal MCP 合約，以反映藥房福利從管理護理轉換為服務費。
- 為 MCP 創建新的 Medi-Cal Rx 全部計劃信，以及針對縣級的提供商和其他關鍵合作夥伴的其他相關信息通知。
- 為 Medi-Cal MCP 建立新一份與 Medi-Cal Rx 相關的醫療管理醫療保健所有計劃書，從監管、合規和申報的角度提供指導。
- 更新中卡 MCP 費率。
- 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.
三十三. DHCS 如何確保轉換為 Medi-Cal Rx 的受益人不會遇到其護理中斷和/或無法獲得必要的處方藥？
To assist Medi-Cal beneficiaries, providers (prescribers and pharmacies), and Managed Care Plans (MCPs) with the Medi-Cal Rx full Assumption of Operations (AOO), DHCS will provide various Medi-Cal Rx Transitional Supports and Services (TSS) between January 1, 2021, through Medi-Cal Rx full AOO on January 1, 2022, as described in more detail in question #30 above and has developed and will implement a multi-faceted pharmacy transition policy. The pharmacy transition policy will use strategies such as “grandfathering” previously approved prior authorization (PA) requests 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. The transition period also includes a 180-day period where DHCS will not require PA for existing prescriptions without previously approved PAs from their applicable Medi-Cal MCPs, for drugs not on the Medi-Cal Contract Drugs List (CDL), or that otherwise have PA requirements under Medi-Cal Rx. This policy does not apply to new prescriptions or drugs that do not have PA requirements under Medi-Cal Rx. During this transition period, Magellan will provide system messaging, reporting and outreach to provide for a smooth transition to Medi-Cal Rx. This pharmacy transition period will facilitate a smooth, productive transition, ensuring that Medi-Cal beneficiaries do not experience disruption in their access to medically necessary prescriptions while maintaining compliance with all state and federal laws related to the Medi-Cal pharmacy benefit. DHCS’ Pharmacy Transition Policy is available on the Medi-Cal Rx Transition webpage.
三十四. DHCS 是否會開發 Medi-Cal Rx 過渡計劃，如果是，該計劃將包括哪些組件？
是的，根據提案請求 #19 -96125，附件 A，附件 I — 工作範圍 — 收購，麥哲倫醫療補助管理局有限責任公司（MMA）和 DHCS 將制定 Medi‑Cal Rx 藥房過渡方法/計劃，至少包括以下流程：
- 為 Medi-Cal 藥房和處方提供足夠的通知和靈活性，以便採取所有必要的步驟，以適應新的 Medi-Cal Rx 承包商、Medi-Cal 合同藥物清單 (CDL) 和相關流程。
- 向 Medi-Cal 受益人提供有關轉型的適當通知和有關 DHCS 和 Medi-Cal 託管護理計劃（MCP）的相關資料。
- 提供指示，以便在過渡期間分配藥物獲得預先許可（在 Medi-Cal Rx 完全執行的藥物治療（AOO）之前開始的藥物，而無需先獲得批准的 PA 即可發放和計費。 然而，潛在的藥物使用檢討（DUR）對藥物安全的要求仍將適用。
- 藥房、供應商和受益人協助，包括確保受影響人士收到有關 Medi-Cal Rx 藥房過渡期及相關程序的適當通知和其他信息。
三十五. DHCS 將在 Medi-Cal Rx 過渡計劃中使用哪些策略，以確保受益人順利有效地過渡到 Medi-Cal Rx？
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.
三十六. Medi-Cal 管理護理計劃 (MCP) 是否應該在 Medi-Cal Rx 完全承擔運作（AOO）或之前被 Medi-Cal MCP 裁定和批准的任何事先授權（PA）取消和/或取消任何前面授權（PA）？
否，Medi-Cal MCP 不應該停止和/或取消此類 PA，同樣不應該在 Medi-Cal Rx 完整 AOO 之前自動過期授權。 DHCS 和 Medi-Cal MCP 應採取必要措施，確保 Medi-Cal 受益人在轉換至 Medi-Cal Rx 期間，繼續獲得醫療上必要的藥房福利和服務。
數據摘要, 電子訪問, & 其他臨床支持
三十七.Medi-Cal Rx 是否會為 Medi-Cal 提供者、Medi-Cal 託管護理計劃（MCP）和其他實體提供藥房數據和必要的電子訪問權限，以支持護理協調？
是的，Medi-Cal Rx 將（至少每天）向 Medi-Cal MCP 提供數據摘要，以支持受益人護理協調、執行藥房遵守臨床方面以及疾病和藥物管理的責任。 DHCS 繼續探索有關心理健康和藥物使用障礙計劃的數據摘要的選項和建議，並將在此領域吸引主要利害關係人。 任何協議的解決方案將在 Medi-Cal Rx 完全承擔運作後實施。
此外，Medi-Cal Rx 將通過安全入口網站為所有 Medi-Cal 提供者（處方和藥房）和 Medi-Cal MCP、精神健康和藥物使用障礙計劃，以及 DHCS 指定的其他實體提供適當的實時訪問 MMA 的電子環境。
三十八. Medi-Cal Rx 將為 Medi-Cal 託管護理計劃（MCP）提供哪些額外的臨床和護理協調支持？
MMA 將向 Medi-Cal MCP 提供額外的臨床和護理協調支持，以滿足他們與 Medi-Cal 受益人護理協調、遵守藥物和其他相關責任相關的合約義務，通過：
- 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.
- 維持專屬的 Medi-Cal MCP 臨床聯絡人員的足夠人員比率，以確保 Medi-Cal MCP 維持這種接入水平。
- Providing access to the Medi-Cal MCP clinical liaisons through Medi-Cal Rx’s dedicated Integrated Voice Response system to assist and resolve clinical pharmacy-related issues.
For more information, please see the Medi-Cal Rx MCP Clinical Liaison Policy and the Medi-Cal Rx Website and Pharmacy Portal Policy.
提供者外展, 教育, & 培訓
三十九.DHCS 為 Medi-Cal Rx 提供和/或計劃為 Medi-Cal Rx 提供哪些類型的提供者外展、教育和培訓以及相關支持？
DHCS 與 MMA 合作致力提供 Medi-Cal 供應商的客戶支持服務，包括但不限於以下內容：
- 客戶服務中心 (CSC) 支援所有提供者電話，每天二十四 (24) 小時、每週七 (7) 天、每年三百六十五 (365) 天 (不包括核准假期除外)，或除非 DHCS 另有指示。
- 向 Medi-Cal 提供者、Medi-Cal 託管護理計劃（MCP）和其他實體提供外展、培訓和通知材料。
- 基於 Web 的服務，支持 Medi-Cal Rx 的通信和工具。
- Real-time access into MMA’s electronic environment via a secure portal.
- 其他服務和支持以確保順暢有效的過渡（例如，Medi-Cal Rx 過渡性支持和服務（TSS）和 180 天藥房過渡期）。
此外，MMA 的 Medi-Cal Rx CSC 代表將代表 DHCS 代表行動，在各種場地向提供者（處方和藥房）藥房計費代理和計劃合作夥伴轉發和提供有關 Medi-Cal Rx 信息和培訓材料的專業知識/支持。 如需詳細資訊，請參閱申請書 #19 -96125 附件 A、附件 II — 工作範圍 — 營運 — 教育與外展。
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.
會員客戶服務 & 相關支持
三十九.DHCS 為 Medi-Cal Rx 提供和/或計劃為 Medi-Cal Rx 提供哪些類型的 Medi-Cal 受益客戶服務和相關支持？
DHCS 與麥哲倫醫療補助管理有限責任公司（MMA）合作，致力於提供會員客戶服務和相關支持，包括但不限於以下內容：
- Medi-Cal Rx 客戶服務中心（CSC）支持所有會員電話，每天 24 小時，每週 7 天，每年 365 天，不包括批准的假期，或除非 DHCS 另有指示。
- 通過不同途徑向 Medi-Cal Rx 相關的資料提供資料，包括但不限於通過美國郵政和網絡式服務的適當通知（例如，支持 Medi-Cal Rx 的通信和工具的外部網站）。
- 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. - 互動式語音響應 (IVR) 系統，可提供：
- 記錄的信息
- 自助服務選項
- 能夠向客戶服務要求跟進，例如回撥電話或通過郵件或電子郵件提供的信息。
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.
會員資格，費用分擔，& 其他健康保障相關問題
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. 如果 Medi-Cal 受益人有其他健康保障（OHC），哪些醫療保障和福利計劃被視為主要？
Medi-Cal’s overarching OHC policy is not changing and, in most instances, Medi‑Cal is the payer of last resort.
44. Medi-Cal Rx 會影響同時擁有醫療保險和醫療保險（D 部分）保障的 Medi-Cal 受益人嗎？
不Medi-Cal Rx 不會影響或以其他方式改變同時擁有 Medi-Cal 和聯邦醫療保險（D 部分）保障的 Medi-Cal 受益人的任何藥物保障。 Medi-Cal 可能包括聯邦醫療保險（第 D 部分）可能不支付的處方藥福利，因此 Medi-Cal 受益人也應與其提供商討論。
Medi-Cal 服務收費補償方法
45. 對於 Medi-Cal 藥房，Medi-Cal 服務藥房費用補償方法是如何制定的，以及其組成部分是什麼？
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.
- 醫療保健服務部（DHCS）將藥物成分成本計算為以下最低的成本：
- 藥物的全國平均藥物採購成本（NADAC），或者在沒有 NADAC 時，批發採購成本（WAC）+ 0%，或
- 聯邦上限 (FUL)，或
- 最大允許成分成本 (MAIC)。
- 專業分配費（根據醫療補助和非醫療補助年度藥房索償金額的總額 [即分配處方] 為兩層）：
- > 或 = 每年 90,000 宗索償：10.05 美元
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
政策考量
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:
- 所有美國食品和藥物管理局 (FDA) 批准的涵蓋門診藥物，根據醫療保險中心 & 醫療補助服務（CMS）定義，視醫療需要而定。
- 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.
五十. DHCS 如何決定從合約藥物清單 (CDL) 中添加或刪除藥物？
DHCS 可根據（1）從製造商、醫生和/或藥劑師提出的外部個人藥物請求（IDP）要求，或（2）DHCS 啟動的 IDP 審查（如果適用），將藥物添加到 Medi-Cal CDL 中。 在收到 IDP 後，DHCS 會對該要求進行廣泛審查，並考慮基於證據的文獻、行業最佳做法以及以下藥物審查標準，這些準則載於福利和機構守則第 14105.39 (c) (1) 條中概述了 及 (2)：
- 藥物的安全性
- 藥物的有效性
- 對藥物的基本需求
- 濫用藥物的可能性
- 藥物對計劃的成本
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.有沒有與 Medi-Cal Rx 有任何法定更改？
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.
- 消除了 Medi-Cal 服務處方共付費。
- 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.
五十二. 對於需要事先授權（PA）的藥物，處方人員或提供者是否需要每次發放藥物時提交 PA？
否，PA 可以涵蓋在批准的 PA 期間內分配的多個填充物。
53.DHCS 是否進行政策變更以允許多年的事先授權 (PA) 批准？
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.衞生護理服務部 (DHCS) 會否考慮修改政策以增強和/或擴展自動裁判功能？
作為 Medi-Cal Rx 的一部分，DHCS 繼續增強和/或擴展自動裁判功能（例如，自動索償批准和付款），以減少需要手動審查的事先授權 (PA) 要求的藥物數量。
五十五.Medi-Cal Rx 是否包括阿片類藥物管理服務？
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.
此外，作為 Medi-Cal Rx 的一部分，DHCS 作為提案請求（RFP）的一部分徵求提案，以進一步探索超越聯邦法律要求的增強型阿片藥物管理使用管理工具。 未來，DHCS 將考慮實施建議的增強型阿片類藥物管理服務。
五十六. Medi-Cal Rx 會包括藥房鎖定計劃嗎？
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. 我在哪裡可以找到適用於 Medi-Cal 託管護理計劃（MCP）的 Medi-Cal Rx 全部計劃信函，該信從政策和計劃方式的角度提供指導？
DHCS’ new Medi-Cal All Plan Letter APL 20-020 for Medi-Cal MCPs can be found on DHCS’ website.
五十八. 我在哪裡可以找到與 Medi-Cal Rx 相關的醫療管理醫療保健部所有計劃書，該書可以從監管、合規和申報角度提供指引？
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?
The IN 20-03 for CCS and GHPP programs relative to Medi-Cal Rx is available on DHCS’ website.
六十. 我在哪裡可以找到行為健康信息通知（BHIN），該通告提供與 Medi-Cal Rx 相關的縣心理健康和藥物使用障礙（SUD）服務的指導？
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.
預先授權 ／ 使用率管理
六十一. 根據 Medi-Cal Rx，預先授權（PA）請求將如何被審查和裁決？
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.是否允許 Medi-Cal 託管護理計劃（MCP）與 Medi-Cal Rx 承包商簽約以執行事先授權（PA）？
不由於 Medi-Cal Rx 於 2022 年 1 月 1 日完全承擔營運後，Medi-Cal MCP 將不再以合約方式負責 Medi-Cal 藥房福利，所有 PA 裁決和相關程序將由 MMA 交付，符合合同要求和 DHCS 的指導。
340B 聯邦藥品折扣計劃
63. 什麼是聯邦 340B 計劃？
公共衛生服務法案 (第 42 章美國代碼第 256b 條) 的 340B 條設立了一個稱為 340B 藥物定價計劃（340B 計劃）的聯邦計劃，該計劃於 1992 年在採用醫療補助藥物回贈計劃後創建。 美國衛生和人類服務部下的健康資源和服務管理局是一個機構，通過其藥劑事務辦公室管理和管理該計劃。
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. 誰使用 340B 計劃？
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. 我們的處方藥提案與 340B 計劃之間有什麼互動？
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.
2009 年 10 月，加利福尼亞州編制了一項先前存在的保單，規定 340B 受保實體只要向 Medi-Cal 成員派發 340B 的庫存，並在通過 Medi-Cal 服務交付費制度分配時按其實際收購成本 (AAC) 計算這些藥物，並符合福利和機構守則（W & I 守則）第 14105.46 條。 340B 實際採購成本計費要求僅適用於服務交付費系統。
在託管服務交付系統中，分發給 Medi-Cal 會員的 340B 藥物不受 Medi-Cal 服務收購費用及成本計費要求的規定。 這允許受保的實體和 Medi-Cal 託管護理計劃（MCP）和/或合同的藥房福利經理（PBM）協商補償安排，從而導致管理照護提供系統中的 340B 受保實體獲得更高的補償，相比這些實體在 Medi-Cal 服務提供費用系統中的退款方式相比。 這些利潤不會與國家分享，國家也不知道這類利潤的金額。
Medi-Cal Rx 允許政策的統一性，並改善通過 340B 計劃分配和計費的藥物的索償監督。
66.Medi-Cal Rx 是否阻止提供商繼續作為 340B 實體？
不此外，該建議並不改變或消除加利福尼亞州的 340B 計劃。
67. 衞生護理服務部 (DHCS) 如何解決有關 Medi-Cal Rx 對 340B 計劃的管理影響所提出的關注？
DHCS 認識到我們的安全網供應商的重要作用，以及他們為 Medi-Cal 受益人所做的重要工作。 DHCS 已經合作並繼續合作，並代表醫療設施和團體與各有關人士和利益相關者進行討論，以更好地了解實施 Medi-Cal Rx 對其 340B 計劃和相關流程的影響，並進一步討論緩解潛在的方案。
68. DHCS 將如何為非醫院 340B 診所分配和/或提供額外付款池？
DHCS 召開一個利害關係人工作小組，制定向符合條件的非醫院 340B 社區診所分配補充資金的方法。 工作小組主題包括收取補充款項的資格準則、每個財政年度可用的集區資助總額，以及在符合條件的非醫院 340B 社區診所之間分配池資金的準則，包括所產生的補充金的時間、頻率和金額。 國家計劃修正案（SPA）已獲批准。 此外，在 28 月 2023 發布的公告指出，衞生署會根據《議會條例草案 80》的規定，就符合條件的非醫院 340B 社區診所訪問日期為服務日期由 7 月 1、2023 至 12 月 31 2023 日期內支付補助金。
Medi-Cal Rx 投訴 ／ 異議解決方案 & 上訴程序
69. Medi-Cal 受益人需要哪些投訴和異議解決程序來解決藥房福利問題？
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. Medi-Cal Rx 將處理哪些與藥房相關的投訴和異議？
All pharmacy-related complaints and grievances for Medi-Cal Rx services provided after the Medi-Cal Rx full Assumption of Operations on January 1, 2022, will be handled through Medi‑Cal Rx’s Customer Service Center for triaging, research, and resolution. For more information, please see DHCS’ Medi-Cal Rx Complaints and Grievances Policy.
71. 衞生護理服務部如何處理 Medi-Cal Rx 完全承擔運作（AOO）或之前，對 Medi-Cal 託管護理計劃（MCP）提供的藥房相關服務所產生的投訴和異議？
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.
Medi-Cal Rx 客戶服務中心（CSC）在 Medi-Cal Rx 完整 AOO 後收到的藥房相關投訴和投訴，將由 Medi-Cal Rx 全部 AOO 或之前所提供的服務，將由 Medi-Cal Rx CSC 轉移到適當的醫療中心，以完全解決。
Medi-Cal Rx CSC 將建議 Medi-Cal MCP 成員，如有關藥房相關的投訴和抱怨，他們應該與其 MCP 聯繫。
Medi-Cal Rx 的影響，Medi-Cal MCP 成員就在 Medi-Cal Rx 完整 AOO 或之前提供的藥房相關服務向其醫療中心提交投訴和投訴的權利不受 Medi-Cal Rx 的影響。
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. Medi-Cal 受益人需要哪些上訴機制來解決藥房福利問題？
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. 如果 Medi-Cal 受益人希望進行國家公平聽證會，是否有時間限制？
是的，Medi-Cal 受益人只有 90 天的時間要求聆訊，這符合適用的州法律。
75. Medi-Cal 受益人可以在等待州公平聆訊決定期間獲得治療嗎？
是的 若要繼續接收拒絕通知停止和/或更改的 Medi-Cal Rx 服務，Medi-Cal 受益人必須在 NOA 日期起計十天內，或在通知說您的治療將停止或更改的日期之前要求進行國家聆訊，以較晚者為準。
在要求國家公平聽證會時，Medi-Cal 受益人應表明他們希望在聽證過程中繼續獲得 Medi-Cal Rx 服務。 請注意，最多可能需要 90 天才能決定案件，並將最終裁定發送給 Medi-Cal 受益人。
76.Medi-Cal 受益人可以要求加快國家公平聆訊？
是的Medi-Cal 受益人可以通過向醫生提交一封信來要求加快聆訊，說明長達 90 天等待他們的生命和/或健康會對他們的生命和/或健康造成危險。 Medi-Cal 受益人應與聽證要求一併發送信件。 有關國家聆訊程序的更多信息，請訪問 DHCS 的 Medi-Cal Fair 聽證會網站。
77. 對於 Medi-Cal 提供者和/或管理護理計劃（MCP）對 Medi-Cal Rx 保障決定的上訴，DHCS 是否會建立一個獨立的 Medi-Cal Rx 外部上訴程序，在其中獨立醫療專家審查決定？
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.
七十八. 哪些藥房相關的上訴將通過 Medi-Cal Rx 處理？
七十九.衞生護理服務部如何處理 Medi-Cal Rx 完全承擔運作 (AOO) 或之前，針對 Medi-Cal 管理護理計劃（MCP）受益人提出的上訴？
Medi-Cal MCP 必須解決所有在 Medi-Cal Rx 完整 AOO 或之前對藥房相關服務的 MCP 決定而引起的所有 Medi-Cal MCP 受益人的上訴。 Medi-Cal MCP 成員向管理健康護理部提出上訴的權利，包括但不限於獨立醫療審查的權利，對 Medi-Cal MCP 在 Medi-Cal Rx 完整 AOO 或之前提供的藥房相關服務，不受 Medi-Cal Rx 的影響。
財政影響 ／ 評估
80. Did the Department of Health Care Services (DHCS) complete a fiscal analysis prior to the transition?
是的DHCS 完成了 Medi-Cal Rx 的財務分析，並公開分享此信息。 DHCS 預計在 2023-24 年之前，一般基金（GF）的年度儲蓄約為 3.09 億美元。 DHCS 將 Medi-Cal Rx 的財政預估計納入為每兩年的 Medi-Cal 估算程序的一部分，並將在未來持續對財政分析提供必要的調整（如果有）。
81.我們預計在 2023-24 年期間的一般基金（GF）年儲蓄為 3.09 億元的要素是什麼？
預計到 2023-24 年度 GF 節省 3.09 億美元的元素包括但不限於以下因素：
- 由於藥物使用率從託管照護提供系統轉移到服務費交付系統而導致的額外州補充藥物回贈。
- 針對具有三 (3) 或更多一般相等選項的藥物實施最大允許成分成本 (MAIC)。
- 降低各種 Medi-Cal 託管護理計劃（MCP）使用的多家藥房福利經理的管理職能相關的成本。
- Medi-Cal 服務費補償方法，其中包括 10.05 美元/13.20 美元的分配費。
- 為非醫院 340B 診所提供的新額外補助金，在 2021 至 22 年度財政預算案中包括在 2021 年 1 月 2022 的 Medi-Cal Rx 完全承擔運作效率。1 有關更多信息，請參閱上面的問題 #70。
正如上述問題 #80 所述，對 Medi-Cal Rx 財政估算的任何調整，包括儲蓄預測，將作為每兩年的 Medi-Cal 估算程序更新。
其他/其他資料
八十二.Medi-Cal Rx 是否包括郵購藥房選項？
是的通過 Medi-Cal Rx 中提供郵購選項。 如果藥房是已註冊的 Medi-Cal 藥房提供商，藥房可能會在現場或通過郵購服務分發藥。 衞生護理服務部（DHCS）確保繼續為 Medi-Cal 藥房服務提供有效的郵購服務選項。
83.衞生護理服務部是否公開 Medi-Cal 藥房補充藥品回贈合約？
不州和聯邦法律都保護補充藥物回贈合同的機密性。
84.Medi-Cal Rx 承包商是否需要與現有網絡中的現有藥房簽約？
不麥哲倫醫療補助管理局有限責任公司（MMA）沒有與任何提供商簽訂合同。 醫療保健服務部（DHCS）保留所有提供者註冊活動以及 Medi-Cal 藥房網絡的維護。
84.Medi-Cal 服務費註冊有多少家有效的加州持牌藥房？
根據衛生護理服務部（DHCS）數據，根據 2023 年 1 月，6,547 家加州持牌藥房提供商註冊 Medi-Cal 服務費用。
85.Medi-Cal 是否致力註冊屬於管理護理計劃（MCP）網絡但未註冊 Medi-Cal 服務費用的藥房？
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.Medi-Cal 管理護理計劃（MCP）和其他實體將以什麼角色參加 Medi-Cal 全球藥物使用檢討（DUR）委員會和其他醫療護理服務部（DHCS）驅動的藥房委員會的會議？
目前和正在進行過渡後，DHCS 預期其 Medi-Cal MCP 和其他有關人士將繼續參加與 Medi-Cal 全球 DUR 董事會和其他 DHCS 驅動的藥房委員會相關的會議，視需要。 此外，DHCS 持續積極評估和評估如何更有效地與 Medi-Cal MCP 和其他實體進行與 Medi-Cal 藥房政策相關的討論和決策中進行未來的討論和決定。
87.衛生護理服務部（DHCS）是否提供有關 Medi-Cal Rx 的更新和新聞訂閱服務？
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.