Prescriptions & Part D
Prescriptions & Part D
New members in SCFHP Cal MediConnect may be taking drugs that aren't in our Drug List or that are subject to certain rules, such as prior authorization or step therapy. Current members may also be affected by changes in 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.
To get a temporary supply of a drug, you must meet the two rules below:
- 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.
- 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.
- 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.
- You have been in the plan for more than 90 days and 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) and you have recently filled a prescription for a drug, SCFHP will cover a new 31-day transition supply of the drug for you to use in your new setting. This will take care of any restrictions that could exist due to refilling your prescription too soon.
- You were in the plan last year.
To ask for a temporary supply of a drug, call Customer Service.
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 Customer Service to ask for a list of covered drugs that treat the same medical condition. The 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 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 without limits.
- If your provider says you have a good medical reason for an exception, he or she can help you ask for one.
- To learn more about asking for an exception, see Chapter 9, Section 6.3 of the Member Handbook.
- If you need help asking for an exception, you can contact Customer Service at 1-877-723-4795 (TTY: 1-800-735-2929 or 711), Monday through Friday, 8 a.m. to 8 p.m.
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 cheaper drug comes along that works as well as a drug on the Drug List now.
- We learn that a drug is not safe
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 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 see the Cal MediConnect List of Covered Drugs (Formulary).
We will tell you when a drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a drug.
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 cheaper drugs work just as well.
- Move a drug to a higher or lower cost-sharing tier.
- Add or remove a limit on coverage for a drug.
- Replace a brand-name drug with a generic drug.
If any of the changes below affect a drug you are taking, the change will not affect you until January 1 of the next year:
- We move your drug into a higher cost-sharing tier.
- We put a new limit on your use of the drug.
- We remove your drug from the Drug List, but not because of a recall or because a new generic drug has replaced it.
Before January 1 of the next year, you usually will not have an increase in your payments or added limits to your use of the drug. The changes will affect you on January 1 of the next year.
In the following cases, you will be affected by the coverage change before January 1:
- If a brand name drug you are taking is replaced by a new generic drug, we must give you at least 60 days’ notice about the change.
- We may give you a 60-day refill of your brand-name drug at a network pharmacy.
- You should work with your provider during those 60 days to change to the generic drug or to a different drug that the plan covers.
- You and your provider can ask us to continue covering the brand-name drug for you. To learn how, please see the Cal MediConnect List of Covered Drugs (Formulary).
- If a drug is recalled because it is found to be unsafe or for other reasons, we will remove the drug from the Drug List. We will tell you about this change right away.
- Your provider will also know about this change. He or she can work with you to find another drug for your condition.
If there is a change to coverage for a drug you are taking, we will send you a notice. Normally we will let you know at least 60 days before the change.
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, Monday through Friday, 8 a.m. to 8 p.m. TTY/TDD users should call 1-800-735-2929 or 711. The call is free.
(8:00 a.m. - 8:00 p.m.
Monday - Friday)
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.
This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook.
Enrollment in Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) depends on contract renewal. CMS (the Centers for Medicare & Medicaid Services) must approve SCFHP Cal MediConnect each year. You can continue to get health coverage as a member of our plan only as long as we continue to offer the SCFHP Cal MediConnect Plan for the year in question and CMS renews its approval of the plan. Even if SCFHP leaves the program, you will not lose health coverage. If SCFHP decides not to continue for the next calendar year, we must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.
Last updated 12/31/2018