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​​​Medi-Cal Rx

​​​​Overview​

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).

Transitioning pharmacy services from MC to FFS will, among other things:
  • Standardize the Medi-Cal pharmacy
    DHCS has completed its review of the Conflict Avoidance Plan (CAP) submitted by Magellan Medicaid Administration (MMA) and announced a January 1, 2022 implementation date.
    benefit statewide, under one delivery system.
  • 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". 

Other changes resulting from the transition to FFS include:
  • ​Apply statewide utili​zation management protocols to all outpatient drugs.
  • Strengthen California's ability to negotiate state supplemental drug rebates with drug manufacturers.

NOTICE

12/10/21 - All batch pharmacy Computer Media Claims submitted after 5:00 pm on 12/10/21 will be rejected by CA-MMIS McWeb in the Monday 12/13/21 batch cycle.

Resources and Reference Materials

The following are resources and reference materials for beneficiaries and providers regarding Medi-Cal Rx services:​
  • Medi-Cal Rx Claim Edits and Prior Authorization Reinstatement Plan:​  Added 6/7/2022. DHCS is seeking feedback by June 10, 2022, on a phased approach for the reinstatement of claim edits and prior authorizations, and the phasing out of the Transition Policy. ​Medi-Cal Rx Reinstatement of Prior Authorizations and Retirement of the Transition Policy Phases II, III, and IV slides have been released and can be found here​.​
  • 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 February 23, 2022, 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, to help support the Medi-Cal Rx transition. During this transition period, Magellan will provide system messaging, reporting and outreach to provide for a smooth transition to Medi-Cal Rx.​​
  • 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 April 8, 2021 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 will launch 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 they can access 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 February 08, 2022, 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).

  • Medi-Cal Rx 30-Day Beneficiary Notice: This notice will be received by all FFS Medi-Cal beneficiaries members on December 1, 2021. The letter provides beneficiaries information regarding changes to how their pharmacy benefits will be administered beginning January 1, 2022, along with contact information for further questions, and recommended steps to help navigate potential impacts.

Stakeholder Engagement​

As part of this transition, DHCS is committed to working with its external partners (including but not limited to, MCP, Counties, Providers, Consumer Advocates, and Beneficiaries) to ensure a smooth and successful transition through the following:
  • ​Publicly releasing draft-informing materials (such as the Request for Proposal, provider and beneficiary notices, All Plan Letters, etc.) for comment.
  • Ensuring MCPs, Counties, providers, consumer advocates, and beneficiaries receive timely and accurate information relating to the transition and associated implementation activities. 
  • Providing status updates and gathering stakeholder feedback through various DHCS-sponsored public meetings.
Note: In addition to stand-alone meetings, DHCS will be looking to leverage existing meetings and workgroups (e.g. stakeholder advisory committee, consumer stakeholder focus workgroup, Medi-Cal Medical Director’s meetings) to provide status updates on implementation efforts and activities related to Medi-Cal Rx.

For individuals with disabilities, the Department will provide assistive devices such as sign-language interpretation, real-time captioning, note takers, reading or writing assistance and conversion of training or meeting materials into Braille, large print, audiocassette, or computer disk. To request such services or copies in an alternate format, please call or write:

Harry Hendrix
Department of Health Care Services
Pharmacy Benefits Division, MS 4604
Sacramento, CA 95814
Phone Number: (916) 552-9500​​
Email: RxCarveOut@dhcs.ca.gov
Please note, the range of assistive services available may be limited if requests are received less than ten working days prior to the meeting or event.

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:

  • Roles and responsibilities of DHCS, the Medi-Cal Rx Contractor, and Medi-Cal Managed Care Plans
  • DHCS' implementation strategies, tools, and timelines, including but not limited to, provider education and outreach and beneficiary notifications
  • Medi-Cal pharmacy policy development, which will include the scope of the carve out, prior authorization, and utilization management protocols
  • Changes to existing Medi-Cal pharmacy committees
Post-transition, the Medi-Cal Rx Advisory Workgroup meetings will focus on gathering information, experiences and/or feedback from workgroup members to help refine Medi-Cal Rx processes and policies on an ongoing basis. The meetings will be open to the public, and in-person public comment will be accepted for the last 30 minutes of each meeting. Additional details, including but not limited to check-in and parking information, will be posted with the agenda at least 10 days prior to each meeting.

Medi-Cal Rx Advisory Workgroup Meeting schedule

Medi-Cal Rx Public Forum

Beginning in July 2019 and continuing throughout calendar year 2020, DHCS has hosted and will continue to host one (1) hour Medi-Cal Rx Public Forums in-person and via webinar to provide status updates to help ensure that the broader stakeholder community is kept up-to-date about Medi-Cal Rx implementation activities and timelines. All Medi-Cal Rx Public Forum meeting dates and times are listed below. All interested organizations and entities, including but not limited to, hospitals, clinics, health plans, counties, pharmacies, tribal health programs, and consumer advocates, are invited to participate.

Medi-Cal Rx Public Forum Schedule

DHCS will release additional information as well as reminder notices through various DHCS stakeholder email distribution lists. In addition, DHCS will also post a final agenda at least 10 days prior to each meeting.

​Contact Us​

For general questions ​​​​​​​relating to Medi-Cal Rx, please direct your comments and questions to RxCarveOut@dhcs.ca.gov​.

Last modified date: 12/12/2022 3:57 PM