WHAT DO PATIENTS NEED TO KNOW ABOUT MEDI-CALRX?
By Lynne Kinst, Executive Director of the Hemophilia Council
On April 1, 2021 California is launching Medi-CalRx, a new program which changes the way the State of California processes payments for prescription drugs, including blood factor products. Medi-CalRx will apply to bleeding disorders patients who receive services from Medi-Cal, CCS and GHPP. You may have heard about this in the news, in emails from the Hemophilia Council of California (HCC) or even in notices from the State of California or your pharmacy provider. But most importantly, you may be concerned about what this means to you.
Previously most medications have been paid as part of Medi-Cal Managed Care – meaning that the state paid a set rate per patient to the insurer and the insurer covers treatment and medication at contracted rates. “Fee-for-service” is when treatment or medications are paid for each service they provide. Blood factor has been “carved-out” of Medi-Cal Managed Care since 2014 and paid under a fee-for-service model, but most other medication has been under managed care. After April 1, under Medi-CalRx all covered outpatient drugs, including Physician Administered Drugs, Medical Supplies and Enteral Nutritional Products will all be paid via fee-for-service agreements. While coverage for blood factor products will be the same – the State believes it can realize significant savings on many other drugs by negotiating contracts for the large volume of drugs which will now be purchased under Medi-CalRx.
The most important fact for you to know about Medi-CalRx is that it should NOT impact your access to the medications you rely upon or the way you receive that medication. Your costs should not change. Most of the changes will take place behind the scenes – in the way that your pharmacy submits their bills to the State and how the state processes and pays your pharmacy. While the State has contracted with a new provider (Magellan) to process the pharmacy claims – unless you have made other changes to your insurance, you should still be able to fill your blood factor and other prescription medications through the same pharmacies you have always used.
While we don’t expect you to be impacted, HCC has monitored the Medi-CalRx proposal closely since it was announced and has had multiple meetings with the State to ensure we and the pharmacies serving the bleeding disorders community understand the changes and that it will not negatively impact anyone’s access to medication, but should you have any problems after April 1st – please let us know as soon as possible so we can assist you and ensure that any systemwide barriers to medication are quickly addressed.
Do you have more questions? The State has launched a website for Medi-CalRx at - https://medi-calrx.dhcs.ca.gov/home/. Patients can check out the information on the “beneficiaries” page (more information will be added to this page before April 1st) or review the FAQ for more information. As always, the Hemophilia Council of California is here to help the bleeding disorders community when you face challenges getting access to your medication or treatment. You can contact us at (916) 571-7771 or email me at lkinst@hemophiliaca.org if you need help.
The Hemophilia Council of California’s mission is to improve access to care and treatment options in order to advance the quality of life for people with bleeding disorders through advocacy, education, and outreach in collaboration with our founding member organizations – Central California Hemophilia Foundation, the Hemophilia Association of San Diego County, the Hemophilia Foundation of Northern California and the Hemophilia Foundation of Southern California.
Statewide HCC represents over 404,000 people with bleeding disorders including von Willebrand disease and hemophilia. HCC helps shape state policy by educating members of the State Legislature and State regulators about what it is like to live with a bleeding disorder in an effort to maintain access to treatment, choice in treatment options and improved quality of life. HCC works to maintain funding for programs such as the Genetically Handicapped Persons Program (GHPP), California Children’s Services (CCS) and Medi-Cal.
