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Pharmacy

The SCFHP drug formulary is a list of preferred generic and brand-name medications in various therapeutic classes that are covered under the SCFHP pharmacy benefit. The Drug Formulary (List of Covered Drugs) exists to allow our providers and clinicians to determine the safest and cost-effective drug therapy possible.

For the DualConnect formulary, please visit the DualConnect List of Covered Drugs page.

The Formulary Drug List applies only to drugs provided by a retail, long-term care or home infusion pharmacy and processed through SCFHP’s Pharmacy Benefit Manager (PBM). It does not apply to drugs used in inpatient settings or furnished by a provider.

Resources

Pharmacy and Therapeutics (P&T) Committee

The SCFHP Pharmacy and Therapeutics (P&T) Committee meets once per quarter to develop and maintain the formulary to ensure that it remains responsive to the needs of our members and providers. The committee is composed of physicians from various medical specialties and pharmacists, whose role is to evaluate clinical drug reviews concerning safety, effectiveness, costs, and decide on the most cost-effective drugs in each class.


The P&T Committee reviews the formulary and updates it based on comprehensive data on efficacy and safety that is available from evidence-based clinical studies, and for which evidence of performance in overall use in a variety of therapeutic settings has been established.

Drug Coverage Exclusions

Drug coverage exclusions include but may not be limited to:

  • Not approved by the United States Food & Drug Administration (FDA),
  • Used as experimental or investigational drugs,
  • Used to treat infertility,
  • Products for cosmetic indications or reasons,
  • Treatment of sexual dysfunction,
  • Dietary supplements and medical foods,
  • Drug Efficacy Study Implementation (DESI) products,
  • Bulk chemicals including those used for compounding, and
  • Drugs purchased outside of the United States and its territories.

Pharmacy Grievances and Appeals

Information on Pharmacy grievances and appeals may be found at the Grievances and Appeals Pharmacy page.

Medi-Cal Members

Drug Coverage

Drug coverage is provided by Medi-Cal Rx instead of SCFHP.

Please visit the Medi-Cal Rx website (www.medi-calrx.dhcs.ca.gov) for more information. You can also call the Medi-Cal Rx Customer Service Center at 1-800-977-2273.

Drugs Administered by Physicians/Clinics

Medi-Cal Rx is responsible for Physician Administered Drugs (PADs) that are billed on a pharmacy claim by a pharmacy. For more information on Medi-Cal Rx, please visit Medi-Cal Rx’s website. PADs that are billed by a physician or clinic on a medical claim should be billed to SCFHP under the medical benefit.

DualConnect Members

Drug Coverage

The SCFHP List of Covered Drugs (Formulary), also called the Drug List, tells you which prescription drugs and non-drug products and items are covered by SCFHP DualConnect. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by SCFHP DualConnect.

The Drug List includes prescription drugs and non-drug products and items. Other drugs, such as some over-the-counter (OTC) medications and certain vitamins, may be covered by Medi-Cal Rx. Medi-Cal Rx covers some OTC drugs when they are written as prescriptions. Please visit the Medi-Cal Rx website (www.medi-calrx.dhcs.ca.gov) for more information. You can also call the Medi-Cal Rx Customer Service Center at 1-800-977-2273.

The drugs on the Drug List are available at pharmacies within the SCFHP pharmacy network. The Drug List does not apply to drugs used in inpatient settings or furnished by a provider.

For the DualConnect List of Covered Drugs (Formulary), please visit the DualConnect List of Covered Drugs page .

Pharmacy Benefit Manager (PBM)

SCFHP's PBM for DualConnect is MedImpact. Pharmacies can contact MedImpact directly for the following:

  • One-time vacation overrides
  • Three-day emergency supply overrides
  • Lost or stolen medication overrides
  • Refill-too-soon overrides due to change in dose
  • Billing questions
  • Price restriction overrides

MedImpact Customer Service Center: 1-800-788-2949

Filing a Medicare Part D Coverage Determination

Procedures for filing a Medicare Part D Coverage Determination include:

  • Download and complete the Medicare Part D Coverage Determination Request Form as instructed here, and fax to MedImpact at 1-858-790-7100.
  • For Part D-related coverage determination questions, please contact MedImpact via phone at 1-800-788-2949.

If you are requesting an exception to what is covered, you must give us a supporting statement explaining the medical reasons for requesting an exception. Our decision about the exception will be faster if you give us this information when you ask for the exception.

  • You can mail or fax the supporting statement to MedImpact at the address and fax number on the Medicare Part D Coverage Determination Request Form.
  • If we do not receive the supporting statement at the time of your request, we will reach out to you for it.

You may ask for a standard or expedited coverage determination.

  • Standard: We must give you our answer within 72 hours after we get your request. If you are asking for an exception, we must give you our answer within 72 hours after we get your supporting statement.
  • Expedited: We must give you our answer within 24 hours after we get your request. If you are asking for an exception, we must give you our answer within 24 hours after we get your supporting statement.

Drugs Administered by Physicians/Clinics

Physician Administered Drugs (PADs) that are covered by Medicare Part B should be billed by the physician or clinic providing the drug for administration under the medical benefit.