Yuav tsum paub txog Rx thiab DHCS hloov tshiab
Lub hnub qub Ratings pab ua kom cov txiaj ntsig zoo tshaj plaws rau cov tswv cuab
Txij li thaum Lub Ib Hlis 1, 2026, Alliance cov tswv cuab tsim nyog tau txais Medi-Cal thiab Medicare tuaj yeem tso npe rau hauv Alliance's TotalCare (HMO D-SNP) txoj kev npaj, uas muab Medi-Cal thiab Medicare cov txiaj ntsig rau hauv ib qho kev npaj.
Lub Chaw rau Medicare & Medicaid Services (CMS) Star Ratings qhov kev pab cuam yog qhov tseem ceeb rau TotalCare txoj kev vam meej thiab nyiaj tau los. Nov yog yam koj yuav tsum paub.
Dab tsi yog Star Ratings?
Lub hnub qub Ratings pab Medicare cov neeg tau txais txiaj ntsig sib piv qhov zoo ntawm Medicare kev noj qab haus huv thiab cov phiaj xwm tshuaj nyob rau hauv lawv qhov chaw pabcuam.
Kev ntsuam xyuas muaj txij li 1 txog 5 hnub qub, nrog 5 hnub qub qhia txog qhov zoo tshaj plaws. Cov qhab nia yog nyob ntawm ntau dua 40 qhov kev ntsuas, siv cov ntaub ntawv los ntawm ntau qhov chaw xws li HEDIS kev ntsuas, cov tswvcuab kev sojntsuam thiab tshuaj noj tshuaj thiab kev ntsuas kev ua haujlwm.
Vim li cas Star Ratings tseem ceeb
CMS khoom plig npaj nrog 4 hnub qub lossis ntau dua nrog cov nyiaj tau txais txiaj ntsig. Cov nyiaj no tuaj yeem siv rau:
- Txo cov nqi rau cov tswv cuab.
- Pab nyiaj pab ntxiv uas tsis yog ib txwm muaj los ntawm Medicare.
Yuav ua li cas cov neeg muab kev pab cuam cuam tshuam
Koj qhov kev koom tes yog qhov tseem ceeb rau txoj kev npaj Star Rating. Nov yog qhov koj tuaj yeem txhim kho peb Cov Kev Ntsuas Hnub Qub:
- Cov ntaub ntawv tiv thaiv kev pabcuam raug raug thiab raws sijhawm.
- Kaw qhov kev zov me nyuam los ntawm kev teem sijhawm thiab ua raws.
- Txhawb kev ua raws li cov tshuaj noj, suav nrog kev rov ua kom rov qab ua kom tiav thiab kev tawm tswv yim txog kev mob tshwm sim.
- Coordinate cov kev hloov mus rau kev saib xyuas kom txo tau kev nyeem ntawv.
- Txhawb kev tiv thaiv kev saib xyuas, suav nrog kev kuaj mob qog noj ntshav thiab lub mis thiab tshuaj tiv thaiv.
- Kev ntes coding thiab cov ntaub ntawv kom raug los cuam tshuam cov tswv cuab cov ntaub ntawv kho mob thiab txhawb nqa HEDIS thiab Star Ratings ntsuas.
- Txhawb kom cov tswv cuab koom nrog hauv kev ntsuas kev noj qab haus huv, kev npaj saib xyuas thiab kev soj ntsuam kev txaus siab.
Yog tias koj muaj lus nug, thov hu rau koj tus kws kho mob tus neeg sawv cev.
Tus kws kho mob muab tshuaj hloov pauv kom paub, pib lub Kaum Ob Hlis 1, 2025
Lub Alliance tau hloov pauv rau tus kws kho mob tau txais txiaj ntsig tshuaj. Koj tuaj yeem nrhiav kev tso cai ua ntej (PA) cov txheej txheem ntawm peb lub vev xaib.
Cov kev hloov pauv yog raws li nram no:
| HCPCS Code | Tshuaj | Hloov | Nyiam Tshuaj |
| GnRH Agonists | |||
| j9217 ua | Leuprolide acetate (Lupron Depot, Eligard 7.5mg) | Tsis xav tau PA | |
| J1950 | Leuprolide acetate (Lupron Depot 3.75mg) | Hloov kho PA cov txheej txheem. | Siv HCPCS code J9217 rau mob qog noj ntshav prostate. |
| j3315 ua | Triptorelin (Trelstar) | Hloov kho PA cov txheej txheem. | |
| j9226 ua | Histrelin cog
(Supprelin LA) |
||
| j3316 ua | Triptorelin XR (Triptodur) | ||
| j9202 ua | Goserelin acetate (Zoladex) hmoov | Cov txheej txheem PA tshiab. | |
| j1951 ua | Leuprolide acetate (Fensolvi) | ||
| j1954 ua | Leuprolide acetate (Lutrate 7.5mg) | ||
| j1952 ua | Leuprolide mesylate (Camcevi) | ||
| Tshiab Biosimilar HCPCS Codes | |||
| q5098 ua | Ustekinumab-Srlf (Imuldosa) | Cov txheej txheem PA tshiab.
|
Infliximab (Remicade, Inflectra, Renflexis, Avsola, Zymfentra)
|
| q5099 ua | Ustekinumab-Stba (Steqeyma) | ||
| q5100 ua | Ustekinumab-Kfce (Yesintek) | ||
| qw 5153 | Aflibercept-Yszy (Opuviz) | Cov txheej txheem PA tshiab. | Bevacizumab (Avastin) thiab ranibizumab (Lucentis) |
| qw 5155 | Aflibercept-Jbvf (Yesafili) | ||
| qw 5154 | Omalizumab-Igec (Omlyclo) | Cov txheej txheem PA tshiab. | |
| qw 5156 | Tocilizumab-Anoh (Avtozma) | Cov txheej txheem PA tshiab. | DMARD (methotrexate, hydroxychloroquine, leflunomide, lossis sulfasalazine) |
| qw 5157 | Denosumab-Bmwo (Stobolo / Osenvelt) | Cov txheej txheem PA tshiab. | Zoledronic acid |
| qw 5158 | Denosumab-Bnht (Bomyntra/Conexxence) | ||
| qw 5136 | Denosumab-Bbdz (Jubbonti/Wyost) | ||
Lub Alliance tau hloov kho cov cai hauv qab no hauv khw muag tshuaj.
- 403-1101 Pharmacy Operations Management.
- Txuas Ntxiv Cov txheej txheem Medi-Cal Rx MCP Portal.
- Daim ntawv txuas B Medi-Cal Rx Tsim Tus Neeg Siv Khoom.
- 403-1150 Pharmacist Service.
Yog xav thov ib daim qauv, thov hu rau Alliance Pharmacy Department ntawm 831-430-5507.
Txheeb xyuas Txhua Daim Ntawv Npaj (APL) hloov tshiab
Lub Department of Health Care Services tau hloov kho DHCS APL 25-012.
Cov kev hloov pauv no tseem ceeb kom paub, vim tias lawv yuav cuam tshuam li cas koj muab kev pabcuam.
Yog xav paub ntxiv txog APL no thiab lwm yam, koj tuaj yeem mus ntsib peb Txhua Daim Ntawv Npaj Cov Ntawv Webpage. Koj tseem tuaj yeem nrhiav Alliance cov cai thiab cov txheej txheem cuam tshuam hauv Alliance Provider Phau Ntawv Qhia.
