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List of covered drugs (Formulary)

The Santa Clara Family Health Plan DualConnect (HMO-DSNP) (SCFHP DualConnect), 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.

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

How can you find a drug on the Drug List?

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

  • Search alphabetically, or
  • Search by medical condition.

To search alphabetically, look for your drug in the Index of Covered Drugs section. You can find it on page I-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. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. 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 finding the medical condition that your drug is used to treat, please call SCFHP DualConnect Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.

You can also use our to look up drugs by name and see if they are on the SCFHP DualConnect Drug List.

What prescription drugs are on the Drug List?

The drugs in the Drug List are the drugs covered by SCFHP DualConnect. 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.”

The prescription drugs included on this List of Covered Drugs are covered by SCFHP DualConnect. Other drugs, such as some over-the-counter (OTC) medications and certain vitamins, may be covered by Medi-Cal Rx. 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 800-977-2273. Please bring your Medi-Cal Beneficiary Identification Card (BIC) when getting prescriptions through Medi-Cal Rx.

SCFHP DualConnect 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,
  • SCFHP DualConnect agrees that the drug is medically necessary for you, and
  • you fill the prescription at a SCFHP DualConnect network pharmacy.

Changes to the Drug List - Formulary change updates and notices

SCFHP DualConnect must follow Medicare 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.

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, or
  • 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 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).

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:

  • Dec 1, 2022 - Changes effective January 1, 2023

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Get a copy of the most recent Drug List (Formulary) go to Member Materials or contact SCFHP DualConnect Plan Customer Service at 1-877-723-4795 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.

Restrictions, rules & limits on drug coverage

For certain prescription drugs, special rules limit how and when our plan covers them. Generally, 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 our plan before you fill your prescription. This is called prior authorization. If you don’t get approval, we 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 may not be covered in the way that you would like. For example:

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

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

  • Ask SCFHP DualConnect 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.” Medi-Cal Rx covers some OTC drugs when they are written as prescriptions by your provider. Please visit the Medi-Cal Rx website (medi-calrx.dhcs.ca.gov) for more information. You can also call the Medi-Cal Rx Customer Service Center at 1-800-977-2273. Please bring your Medi-Cal Beneficiary Identification Card (BIC) when getting your prescriptions through Medi-Cal Rx.

We do not list OTC drugs in our Drug List.

SCFHP DualConnect offers OTC drugs and products as a Part C supplemental benefit. For more information about your supplemental benefits, see Chapter 4 of the Member Handbook.

What is your copay as an SCFHP DualConnect member?

Tiers are groups of drugs on our plan's Drug List. Every drug on our Drug List is in one tier. You have no copays for prescription and OTC drugs on our Drug List. To find the tiers for your drugs, refer to our Drug List.

Tier 1 drugs are generic, brand name, and biosimilar drugs. The copay is $0.

How to request a copy of member materials?

To request a hard copy of the SCFHP DualConnect List of Covered Drugs (Formulary) in the mail, please click here to submit an online request, or call SCFHP DualConnect 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 DualConnect 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 DualConnect Customer Service for help.

If you are more comfortable speaking a language other than English, SCFHP 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 DualConnect materials in written in other languages.

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 DualConnect is an HMO D-SNP with a Medicare and Medi-Cal contract. Enrollment in DualConnect depends on contract renewal.

Last updated 12/27/2022

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