Prescriptions & Part D
Prescriptions & Part D
As an SCFHP Cal MediConnect member, you can fill your prescription at over 250 pharmacy locations in Santa Clara County or by mail-order.
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).
- You generally must use a network pharmacy to fill your prescription.
- Your prescribed drug must be on the plan’s List of Covered Drugs (Formulary), also called the Drug List. For certain prescription drugs, special rules limit how and when the plan covers them.
- If it is not on the Drug List or it has special rules, we may be able to cover it by giving you an exception. For more information, see Coverage Decisions & Exceptions.
- Your drug must be used for a medically accepted indication. This means that the use of the drug is either approved by the Food and Drug Administration or supported by certain reference books.
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 on the Member Materials page in multiple languages.
If you would like to make a complaint or appeal, or file a grievance, go to the Complaints, Appeals & Grievances page.
You can read the SCFHP Cal MediConnect Drug List to learn about the copay for each drug.
Copays are listed by tiers. Tiers are the groups of drugs in the SCFHP Cal MediConnect Drug List.
- Tier 1 drugs have $0 to $3.35 copay, depending on your income. They are generic drugs
- Tier 2 drugs have $0 to $8.35 copay, depending on your income. They are brand name drugs.
- Tier 3 drugs have $0 copay. They are non-Medicare prescription drugs.
- Tier 4 drugs have $0 copay. They are non-Medicare over-the-counter (OTC) drugs.
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.
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.
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.
If you or your provider thinks our rules should not apply to your situation, you should ask us to make an exception. This is called a formulary exception, and it is a type of coverage decision, also called a "drug coverage determination."
For more information, see Coverage Decisions & Exceptions.
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, go to the web page for List of Covered Drugs.
View the Drug List by going to the Cal MediConnect Member Materials page.
You can ask for this information in other formats, such as large print, braille or audio. Call SCFHP 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.
If you have questions regarding your prescribed drugs or want to request a copy of the Drug List, contact Customer Service.
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 have, like medication costs and drug reactions
- How best to take your medications
- Questions or problems you have about your prescription and over-the-counter medication
See Medication Therapy Management for more information.
SCFHP contracts with most chain and independent pharmacies in Santa Clara County. To fill your prescription, show your SCFHP Cal MediConnect member ID card and your doctor’s prescription to any participating pharmacy.
Find a pharmacy by downloading the SCFHP Cal MediConnect Provider and Pharmacy Directory in your language from Member Materials.
You can ask for this information in other formats, such as large print, braille or audio. You can also request a hard copy of the Provider and Pharmacy Directory in the mail. Click here to fill out an online request form, or call SCFHP Customer Service at 1-877-723-4795, Monday through Friday, 8 a.m. to 8 p.m., including holidays. TTY/TDD users should call 1-800-735-2929 or 711. The call is free.
Please note that 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/TDD users should call 1-800-735-2929 or 711.
See Find a Pharmacy for more information.
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. Limitations, copays and restrictions may apply. Benefits and/or copays may change on January 1 of each year. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Copays for prescription drugs may vary based on the level of Extra Help you get. Please contact the plan for more details.
Last updated 12/29/2017