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List of covered drugs (Formulary)

The Santa Clara Family Health Plan (SCFHP) Cal MediConnect Plan (Medicare-Medicaid Plan) List of Covered Drugs, also called the Formulary or 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.

An online, searchable formulary is available in the mySCFHP member portal. Or see the SCFHP Cal MediConnect List of Covered Drugs in Member Materials.

How to request a copy of 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 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

How can you find a drug on the Drug List?

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

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

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, 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. 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.

What prescription drugs are on the Drug List?

The drugs in the Drug List are the drugs covered by SCFHP Cal MediConnect. 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 will cover all medically necessary drugs on the Drug List if:

  • your doctor or other prescriber says you need them to get better or stay healthy, and
  • you fill the prescription at a SCFHP network pharmacy.

Changes to the Drug List - Formulary Change Updates and Notices

SCFHP 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 made during the year can be found here:

To see the most recent Drug List, go to Member Materials.

To get a copy of the most recent Drug List, contact SCFHP.

Call:
Toll-free: 1-877-723-4795 (TTY: 711), Monday through Friday, 8 a.m. to 8 p.m.

Restrictions, Rules and 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 use the lower-cost drug.

For a list of drugs that require step therapy or prior authorization, see 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, see 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 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 on the Drug List?

If you don’t see your drug in the Formulary, it may be because of the following reasons:

  • 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 will not cover the drug, you can do one of these things:

  • Ask 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 covers some OTC drugs when they are written as prescriptions by your provider. These are Tier 4 drugs in the SCFHP Cal MediConnect List of Covered Drugs.

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

You can read the SCFHP Cal MediConnect 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, $8.95) 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 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 formulary.

  • 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.

To learn more about the plan’s benefits, cost-sharing, applicable conditions and limitations, refer to your SCFHP Cal MediConnect 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.

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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