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Prescription drugs

As an Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) member, you can fill your prescription at over 200 pharmacy locations in Santa Clara County and at chain pharmacies nationwide. You can also get a 90-day supply of most prescription maintenance medications for the same copay as a 30-day supply. Talk to your doctor about getting a prescription for a 90-day supply. You can pick it up at an in-network pharmacy or have it mailed to you through MedImpact Direct. To find out more about our mail-order services, visit www.medimpactdirect.com or see the Santa Clara Family Health Plan (SCFHP) Cal MediConnect Member Handbook in Member Materials.

SCFHP will usually cover your drugs as long as you follow the rules:

  • You must have a doctor or other provider write your prescription. This person often is your primary care provider (PCP). It could also be another provider if your PCP has referred you for care.
  • You use a network pharmacy to fill your prescription.
  • Your drug must be on our List of Covered Drugs (Formulary), also called the "Drug List" for short.

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 more information on your prescriptions and Part D benefits and services, click the + buttons below or refer to the SCFHP Cal MediConnect Member Handbook and List of Covered Drugs available in Member Materials in multiple languages.

If you would like to make a complaint or grievance, or file an appeal, go to Complaints, Grievances & Appeals.

Frequently asked questions

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

Every drug on our Drug List is in one of four cost-sharing tiers:

  • Tier 1 drugs are generic drugs. The copay is $0.
  • Tier 2 drugs are brand name drugs. The copay is from $0 to $8.95, 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.

SCFHP Cal MediConnect members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays.

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.

Drug Transition Policy and Process

If you are new to SCFHP Cal MediConnect or your level of care changes, there may be drugs you are taking that are not on the Drug List. In this case, you may still be able to fill your prescription.

See Drug Transition Policy and Process for more information.

Coverage Decisions & Exceptions

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 that is safe and effective. This rule is called a “coverage determination,” also known as a prior authorization.

If you or your provider thinks our rules should not apply to your situation, you should ask us to make an exception. You may also request drugs not on our Drug List to be covered. This is called a formulary exception.

For more information, see Coverage Decisions & Exceptions.

List of Covered Drugs

The SCFHP Cal MediConnect Drug List tells you which prescription drugs are covered by SCFHP. 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. To learn more, see List of Covered Drugs.

You can see the Drug List in Member Materials.

To request a hard copy of the SCFHP Cal MediConnect List of Covered Drugs (Formulary) in the mail, please click here to submit an online request, or call 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 Customer Services, 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

Medication Therapy Management (MTM)

If you take medications for different medical conditions, you may be able to get services, at no cost to you, through a Medication Therapy Management (MTM) program. This program helps you and your provider make sure that your medications are working to improve your health. A pharmacist or other health care professional will review all your medications and talk with you on the phone about:

  • How to get the most benefit from the drugs you take
  • Any concerns you may have, like possible drug side effects
  • How best to take your medications
  • Any questions or problems you have about your prescription and over-the-counter medications

See Medication Therapy Management for more information.

Find a Pharmacy

SCFHP contracts with most chain and independent pharmacies in Santa Clara County. We also contract with chain pharmacies throughout the United States. To fill your prescription, show your SCFHP Cal MediConnect member ID card and your doctor’s prescription to any participating pharmacy.

Find a pharmacy using the "Find a Doctor" search tool or by downloading the SCFHP Cal MediConnect Provider and Pharmacy Directory in your language from Member Materials.

To request a hard copy of the SCFHP Cal MediConnect Provider and Pharmacy Directory in the mail, please click here to submit an online request, or call 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 Customer Services, 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

NOTE: Network pharmacies may have been added or removed after the SCFHP Cal MediConnect Provider and Pharmacy Directory was printed. Please contact Customer Service at 1-877-723-4795 if you have questions regarding pharmacy locations. TTY users should call 711.

See Find a Pharmacy for more information.

Accessibility

You can ask for published materials for free in other formats, such as large print, braille, or audio. Call Customer Service for help.

If you speak a language other than English, language assistance services, free of charge, are available to you. Call Customer Service at 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m. The call is free.

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 01/08/2020

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