加州醫療補助健康保健計劃 Rx
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).
將藥房服務從 MC 轉換為 FFS 將包括：
- 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 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”.
轉換至 FFS 所產生的其他變更包括：
- 將全州的使用管理協議應用於所有門診藥物。
- Strengthen California’s ability to negotiate state supplemental drug rebates with drug manufacturers.
資源及參考資料
以下是受益人和提供者有關加州醫療補助健康保健計劃 Rx 服務的資源和參考材料：
- 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).
利害關係人參與
作為此次過渡的一部分，DHCS 致力於與其外部合作夥伴（包括但不限於 MCP、縣、提供者、消費者權益倡導者和受益人）合作，透過以下方式確保平穩、成功的過渡：
- 公開發草稿提供資料（例如提案申請、供應商和受益人通知、所有計劃信函等）以供意見。
- 確保 MCP、縣、供應商、消費者倡導者和受益人獲得與過渡及相關實施活動有關的及時準確信息。
- 透過 DHCS 主辦的各種公開會議提供狀態更新並收集利害關係人的回饋。
注意：除了獨立會議之外，DHCS 還將尋求利用現有的會議和工作組（例如：利害關係人諮詢委員會、消費者利益相關者聚焦工作小組、Medi-Cal 醫療總監會議），提供與 Medi-Cal Rx 相關的實施工作和活動的狀態更新。
對於殘疾人士，本署會提供手語口譯、即時字幕、筆記、閱讀或寫作協助，以及將訓練或會議資料轉換為點字、大型印刷、音箱或電腦磁碟等輔助設備。如要索取此類服務或以其他格式的副本，請致電或寫信：
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
請注意，如果在會議或活動前不到十個工作天收到請求，提供的輔助服務範圍可能會受到限制。
加州醫療補助健康保健計劃 Rx 諮詢工作小組
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 、加州醫療補助健康保健計劃 Rx 承包商和Medi-Cal Managed Care計劃的角色和責任
- DHCS’ implementation strategies, tools, and timelines, including but not limited to, provider education and outreach and beneficiary notifications
- 加州醫療補助健康保健計劃制定藥房政策，其中包括劃分範圍、事先授權和利用管理協議
- 現有加州醫療補助健康保健計劃藥學委員會的變更
過渡後，加州醫療補助健康保健計劃 Rx 諮詢工作小組會議將重點收集工作小組成員的資訊、經驗和/或回饋，以幫助持續完善加州醫療補助健康保健計劃 Rx 流程和政策。 會議將向公眾開放，並在每次會議最後 30 分鐘內接受面對面的公眾意見。 其他詳細信息，包括但不限於入住和停車信息，將在每次會議前至少 10 天發布會議議程中。
加州醫療補助健康保健計劃 Rx 諮詢工作小組會議日程
會議 #1：二零二零年一月十四日（星期二）
會議 #2：二零二零年三月十八日（星期三）
會議 #3：二零二零年五月二十六日（星期二）
會議 #4：七月 29, 2020 (星期三)
會議 #5：十月 21，2020（星期三）
會議 #6:1 月 25, 2021 (星期一)
會議 #7：九月 13，2021（星期一）
會議 #8：二零二一年十一月八日（星期一）
會議 #9：2022 年 1 月 10 日（星期一）
會議 #10：2022 年三月十四日（星期一）
會議 #11：6 月 2, 2022 (星期四)
加州醫療補助健康保健計劃 Rx 公共論壇
從 2019 年 7 月開始並持續到 2020 日曆年， DHCS已經並將繼續主辦一(1) 小時的加州醫療補助健康保健計劃Rx 公共論壇，以現場方式和網絡研討會的方式提供最新狀態，以幫助確保更廣泛的利益相關者社區隨時了解加州醫療補助健康保健計劃 Rx 實施活動和時間表的最新情況。 所有加州醫療補助健康保健計劃 Rx 公共論壇會議的日期和時間如下所列。 歡迎所有有興趣的組織和實體，包括但不限於醫院、診所、健康規劃、縣、藥房、部落健康專案和消費者權益倡導者參加。
加州醫療補助健康保健計劃 Rx 公共論壇日程
會議 #1：二零一九年七月二十四日（星期三）
會議 #2：二零一九年九月二十六日（星期四）
會議 #3：二零二零年二月二十日（星期四）
會議 #4：二零二零年六月十七日（星期三）
會議 #5：二零二零年九月二十二日（星期二）
會議 #6：二零二零年十二月九日（星期三）
會議 #7：二零二一年九月十五日（星期三）
會議 #8：二零二一年十一月十日（星期三）
會議 #9：2022 年一月十二日（星期三）
會議 #10：2022 年 3 月 16 日（星期三）
會議 #11：2022 年 5 月 11 日（星期三）
DHCS 將透過各種 DHCS 利害關係人電子郵件分發清單發布更多資訊以及提醒通知。 此外，DHCS 還將在每次會議前至少 10 天發布最終議程。
加州醫療補助健康保健計劃 Rx：檔案
All archived material from this page.
聯絡我們
For general questions relating to Medi-Cal Rx, please direct your comments and questions to medi-cal.pharmacybenefits@dhcs.ca.gov.