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Drug transition policy & process

New members in Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) (SCFHP Cal MediConnect Plan) may be taking drugs that are not on our Drug List. Or the drugs may be subjected to certain rules, such as prior authorization or step therapy. Current members may also be affected by changes to our Drug List from one year to the next.

In some cases, we can give you a temporary supply of a drug when the drug is not on the Drug List or when it is limited in some way. This gives you time to talk with your provider about getting a different drug or to ask us to cover the drug.

How can you get a temporary supply of a drug?

To get a temporary supply of a drug, you must meet each of the two rules below:

  1. The drug you have been taking:
    • Is no longer on our Drug List, or
    • Was never on our Drug List, or
    • Is now limited in some way.
  2. You must be in one of these situations:
    • You were in the plan last year.
      • We will cover a temporary supply of your drug during the first 90 days of the calendar year.
      • This temporary supply will be for up to a 31-day supply.
      • If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. You must fill the prescription at a network pharmacy.​
      • Long-term care pharmacies may provide your prescription drug in small amounts at a time to prevent waste.
    • You are new to our plan.
      • We will cover a temporary supply of your drug during the first 90 days of your membership in the plan.
      • This temporary supply will be for up to a 31-day supply.
      • If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 31-day supply of medication. You must fill the prescription at a network pharmacy.
      • Long-term care pharmacies may provide your prescription drug in small amounts at a time to prevent waste.
    • You have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away.
      • We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above temporary supply.
      • If you are transitioning between different levels of care (for example, into or out of a long-term care facility or a hospital), SCFHP Cal MediConnect Plan will cover up to a one-month supply you to use in your new setting. This will take care of any restrictions that may exist due to refilling your prescription too soon.

To ask for a temporary supply of a drug, call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

What do you do about a long-term supply?

When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. Here are your choices:

  • You can change to another drug.
    • There may be a different drug covered by our plan that works for you. You can call SCFHP Cal MediConnect Plan Customer Service to ask for a list of covered drugs that treat the same medical condition. The Drug List is also available on our website in Member Materials. The list can help your provider find a covered drug that might work for you. You or your provider can also use the online formulary search tool to find a drug and see what rules apply to it. This online formulary search tool is updated every month.

OR

  • You can ask for an exception.
    • You and your provider can ask us to make an exception. For example, you can ask us to cover a drug even though it is not on the Drug List, or you can ask us to cover the drug above what we limit

To learn more about asking for an exception, refer to Chapter 9, Section F3 of the SCFHP Cal MediConnect Plan Member Handbook in Member Materials.

If you need help asking for an exception, you can contact SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

To learn more about asking for a coverage decision, such as an exception, click here.

What if there are changes in coverage for your drugs?

Most changes in drug coverage happen on January 1. However, we might make changes to the Drug List during the year. We will send you a notice before we make a change that affects you.

Generally, the Drug List will only change if:

  • A new, cheaper drug comes on the market that works as well as a drug on the Drug List now.
  • We learn that a drug is not safe or
  • A drug is removed from the market.

We may also change our rules about drugs. For example, we could:

  • Decide to require or not require prior approval for a drug. (Prior approval is permission from SCFHP Cal MediConnect Plan before you can get a drug.)
  • Add or change the amount of a drug you can get (called “quantity limits”).
  • Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

For more information on these drug rules, please refer to the SCFHP Cal MediConnect Plan List of Covered Drugs (Formulary) in Member Materials. Or you can use the online formulary search tool to find a drug and see what rules apply to it. This online formulary search tool is updated every month.

Some changes to the Drug List will happen immediately. For example:

  • A new generic drug becomes available. Sometimes, when a new generic drugs comes on the market that works as well as a brand name drug on the Drug list, we may remove the brand name drug and add the new generic drug, but your cost for the new drug will stay the same or will be lower.

When we add the new generic drug, we may also decide to keep the brand name drug on the list but change its coverage rules or limits.

    • We may not tell you before we make this change, but we will send you information about the specific change we made once it happens.
    • You or your provider can ask for an "exception" from these changes. We will send you a notice with the steps you can take to ask for an exception. Please refer to Chapter 9 of the member handbook for more information on exceptions.
  • A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drug's manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know. You should contact your provider to discuss what to do for your medical condition.

We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:

  • The FDA provides new guidance or there are new clinical guidelines about a drug.
  • We add a generic drug that is not new to the market and
    • Replace a brand name drug currently on the Drug List or
    • Change the coverage rules or limits for the brand name drug.

When these changes happen, we will:

  • Tell you at least 30 days before we make the change to the Drug List or
  • Let you know and give you a 31-day supply of the drug after you ask for a refill.

This will give you time to talk to your doctor or other prescriber. They can help you decide:

Accessibility

You can ask for published materials for free in other formats, such as large print, Braille, or audio. Call SCFHP Cal MediConnect Plan Customer Service for help.

If you are more comfortable speaking a language other than English, Santa Clara Family Health Plan can help you. Whether you are contacting SCFHP or visiting a doctor, we have interpreters available. Tell your doctor you would like an interpreter for your visit.

Know your rights

  • You can get an in-person or telephone interpreter at no cost to you. This includes American Sign Language.
  • When you go to the doctor, interpreters are available 24-hours a day.
  • You can ask for SCFHP Cal MediConnect Plan materials in English, Spanish, Simplified Chinese, Tagalog, and Vietnamese.

How can you get an interpreter?

Tell your doctor’s office you would like one. You can do this when you call to set up your next visit. You can also ask us for an interpreter or for translated materials.

Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees.

Enrollment in Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) (SCFHP Cal MediConnect) depends on contract renewal.

Last updated 12/30/2021

H7890_17023W Accepted