Skip to main content
1-800-260-2055

List of covered drugs (Formulary)

The Santa Clara Family Health Plan (SCFHP) Cal MediConnect Plan (Medicare-Medicaid Plan) (SCFHP Cal MediConnect Plan) List of Covered Drugs (Formulary), also called the Drug List, tells you which prescription drugs are covered by SCFHP Cal MediConnect Plan. The Drug List also tells you if there are any rules or restrictions on any drugs, such as a limit on the amount you can get.

Go to mySCFHP member portal, click here to view the online formulary search tool, or refer to the SCFHP Cal MediConnect Plan Formulary in Member Materials.

How can you find a drug on the Drug List?

To find a drug on the SCFHP Cal MediConnect Plan Drug List, you can:

  • Search alphabetically (if you know how to spell the drug), or
  • Search by medical condition (therapeutic class).

To search alphabetically, go to the Alphabetical Listing section of the Drug List. You can find it on page 1.

To search by medical condition (therapeutic class), find the section labeled “List of drugs by medical condition” in the Drug List. You can find it starting on page 1. Then find your medical condition (therapeutic class). For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. If you do not know the name of your drug, or how to spell the name of your drug, or you need help with the therapeutic class of your drug/medical condition, please call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

You can also use our Online Formulary Search tool to look up drugs by name and see if they are on the SCFHP Cal MediConnect Plan Drug List.

What prescription drugs are on the Drug List?

The drugs in the Drug List are the drugs covered by SCFHP Cal MediConnect Plan. The drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

SCFHP Cal MediConnect Plan will cover all medically necessary drugs on the Drug List if:

  • Your doctor or other healthcare provider writes you a prescription, and
  • You meet any applicable coverage requirements or limits on use, and
  • You fill the prescription at a SCFHP network pharmacy.

Changes to the Drug List - Formulary change updates and notices

SCFHP Cal MediConnect Plan must follow Medicare and Medicaid rules when making changes. We may add or remove drugs on the Drug List during the year. Most changes in drug coverage happen on January 1. However, we might make changes to the Drug List during the year. We might:

  • Add drugs because new drugs, including generic drugs, became available or the government approved a new use for an existing drug.
  • Remove drugs because they were recalled or because less expensive drugs work just as well.
  • Add or remove a limit on coverage for a drug.
  • Replace a brand name drug with a generic drug.

We will let you know if there are any changes to the Drug List that may affect you. You will get a letter in the mail.

A list of changes can be found here:

  • February 1, 2022 - Changes effective January 1, 2022

EnglishEspañolTiếng Việt中文Tagalog

  • March 1, 2022 - Changes effective March 1, 2022 and April 1, 2022

EnglishEspañolTiếng Việt中文Tagalog

  • May 1, 2022 - Changes effective May 1, 2022 and July 1, 2022

EnglishEspañolTiếng Việt中文Tagalog

  • June 1, 2022 - Changes effective June 1, 2022

EnglishEspañolTiếng Việt中文Tagalog

  • July 1, 2022 - Changes effective July 1, 2022

EnglishEspañolTiếng Việt中文Tagalog

  • September 1, 2022 - Changes effective September 1, 2022

EnglishEspañolTiếng Việt中文Tagalog

Get a copy of the most recent Drug List (Formulary) go to Member Materials or contact SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

Restrictions, rules & limits on drug coverage

For certain prescription drugs, special rules limit how and when the plan covers them. In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. When a safe, lower-cost drug will work just as well as a higher-cost drug, we expect your provider to prescribe the lower-cost drug.

For a list of drugs that require step therapy or prior authorization, refer to the Drug List in Member Materials.

For more information, see Coverage Decisions & Exceptions.

What is step therapy?

Step therapy is a coverage rule that requires you to first try another drug before we cover the drug you are asking for. For example, if Drug A and Drug B treat the same medical condition, and Drug A costs less, works better, or is more safe than Drug B, we may require you to try Drug A first. If Drug A does not work for you, we will then cover Drug B.

For a list of drugs requiring step therapy, refer to the List of Drugs Requiring Step Therapy in Member Materials.

For more information, see Coverage Decisions & Exceptions.

What is prior authorization?

For some drugs, you or your doctor must get approval from SCFHP before you fill your prescription. This is called prior authorization. If you don’t get approval, SCFHP Cal MediConnect Plan may not cover the drug.

For a list of drugs requiring prior authorization, see the List of Drugs Requiring Prior Authorization in Member Materials.

For more information, see Coverage Decisions & Exceptions.

What if the drug you want to take is not covered?

We try to make your drug coverage work well for you, but sometimes a drug might not be covered in the way that you would like it to be. For example:

  • The drug you want to take is not covered by our plan. The drug might not be on the Drug List. A generic version of the drug might be covered, but the brand name version you want to take is not. A drug might be new and we have not yet reviewed it for safety and effectiveness.
  • The drug is covered, but there are special rules or limits on coverage for that drug. As explained in the section above, some of the drugs covered by our plan have rules that limit their use. In some cases, you or your prescriber may want to ask us for an exception to a rule.

If you learn that SCFHP Cal MediConnect Plan will not cover the drug, you can do one of these things:

  • Ask SCFHP Cal MediConnect Plan Customer Service for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take, or
  • You can ask us to make an exception to cover your drug. For information on how to request an exception, see Coverage Decisions & Exceptions.

Over-the-counter (OTC) drugs

OTC stands for “over-the-counter.” SCFHP Cal MediConnect Plan covers some OTC drugs when they are written as prescriptions by your provider. These are Tier 4 drugs in the SCFHP Cal MediConnect Plan List of Covered Drugs.

What is your copay as an SCFHP Cal MediConnect Plan member?

You can read the SCFHP Cal MediConnect Plan Drug List to learn about the copay for each drug.

For some drugs, you may be charged an out-of-pocket cost called a copay. This is a fixed amount (for example, $9.85) you pay each time you get that drug. You pay the copay at the time you get the drug.

Every drug on our SCFHP Cal MediConnect Plan Drug List is in one of 4 cost-sharing tiers. Copays are listed by tiers. Tiers are the groups of drugs in the SCFHP Cal MediConnect Plan Formulary.

  • Tier 1 drugs are generic drugs. The copay is $0.
  • Tier 2 drugs are brand name drugs. The copay is from $0 to $9.85, depending on your income (highest cost-sharing tier).
  • Tier 3 drugs are non-Medicare prescription drugs that are covered by Medi-Cal. The copay is $0.
  • Tier 4 drugs are non-Medicare over-the-counter (OTC) drugs that are covered by Medi-Cal. The copay is $0.

To learn more about the plan’s benefits, cost-sharing, applicable conditions and limitations, refer to your SCFHP Cal MediConnect Plan Member Handbook. To learn more about how we must establish cost-sharing for low-income subsidy beneficiaries, see the Centers for Medicare & Medicaid Services (CMS) Best Available Evidence policy.

How to request a copy of member materials?

To request a hard copy of the SCFHP Cal MediConnect Plan List of Covered Drugs (Formulary) in the mail, please click here to submit an online request, or call SCFHP Cal MediConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

You can make a standing request to get this document in a language other than English or in an alternate format. We will keep this information on file for future mailings. You do not need to make a separate request each time. To make or change your request, call SCFHP Cal MediConnect Plan Customer Service, submit an online request, or send a request in writing to:

Attn: Customer Service Department
Santa Clara Family Health Plan
PO Box 18880
San Jose, CA 95158

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 Plan) depends on contract renewal.

Last updated 12/30/2021

H7890_17023W Accepted