Medi-Cal Rx Implementation Update: Addressing Concerns and Finding Solutions
Medi-Cal Rx Background
On January 7, 2019, Governor Newsom issued Executive Order (N-01-19) to create a single-purchaser system of drugs in California. Specifically, the Executive Order directs the Department of Health Care Services (DHCS) to transition all pharmacy services for Medi-Cal managed care (MCO) to Fee for Service (FFS), which went into effect on January 1, 2022.
Covered entities under the 340B program will experience a loss in program savings that will significantly impact both patients and health centers. However, the pharmacy transition is NOT eliminating the 340B program, it is essentially ending all pharmacy services (including 340B) under Managed Care.
In this article, we provide an update regarding efforts to implement the pharmacy transition, Medi-Cal Rx. However, if you’re interested in learning more about our advocacy efforts to offset health center losses through the Supplemental Payment Pool (SPP) please see the Advocates newsletter.
Medi-Cal Rx Implementation & Related Concerns from Community Health Centers (CHCs)
CPCA has created a questionnaire (found HERE) to help health centers report to us any operational concerns they are having with implementing the pharmacy transition, including issues with receiving responses from Magellan. CPCA has scheduled monthly meetings (through August 2022) with both the Department of Health Care Services (DHCS) and Magellan leadership to help find resolutions to CHC concerns. CPCA has worked with CHCs to identify the issues that are most pressing to address during these calls. Thus far, we’ve focused on finding a mechanism to share claims data with MCOs and the state if a CHC carves in pharmacy services into their PPS rate and discussing reimbursement issues.
To allow sufficient time for the conversations and help us be as efficient as possible at these meetings, we are only discussing one or two issues per call and inviting the CHCs who reported those issues to join the conversation and share their concerns directly with DHCS / Magellan.
CHCs have reported to CPCA, either through the form or via meetings, that they are still having the following issues:
1. Reimbursement Issues: CHCs have reported reimbursement levels that are at times less than Actual Acquisition Cost (AAC) while others are reporting getting more.
Issues with reimbursement levels for continuous glucose monitors: Free Style Libre (CGM Continuous Glucose Monitor) - preferred brand
2. Continued issues with approvals for Prior Authorizations (PAs):
CHCs continue to have issues in obtaining responses to PAs via CoverMyMeds.
Generally, there seems to be a delay in informing CHCs if PAs have been approved or denied.
3. Sharing claims data with the state for CHCs who carve in pharmacy services to PPS Rate:
A meeting was held to discuss solutions, and DHCS committed to work with Magellan to find a way to submit this data through the Medi-Cal Rx portal. DHCS is working with Magellan to develop sample methods to then share with the CHCs.
4. Issues with finding patients in the system:
When entering all patient info (correct info/demographics), not being able to find patient or it says information is wrong.
5. Issues obtaining medical supplies:
Accessing multiple syringe sizes for hormone therapy (transgender patients need two sizes of needles)
6. Medi-Cal Rx not allowing mail-in orders