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California Department of Healthcare Services

Prescription Drug Discount Program for Medicare Recipients-Frequently Asked Questions

On October 10, 1999, Governor Gray Davis signed into law, Senate Bill 393, which was authored by state Senator Jackie Speier. This new law enables Medicare recipients to obtain their prescription drugs at a cost no higher than the Medi-Cal reimbursement rates. Since it was signed into law, many questions have arisen regarding when and how the program will work. The following Frequently Asked Questions have been written to answer some of these questions.
 
  • What is the "Prescription Drug Discount Program for Medicare Recipients"? When did it begin?
  • How does it work? What do I have to do to use the program?
  • It is a program under which a Medi-Cal pharmacy provider can only charge a Medicare recipient a price that does not exceed what Medi-Cal would reimburse the pharmacy for the same prescription, plus a small processing fee. The program became operational on February 1, 2000.

    Is Medi-Cal paying for my prescription?

    Medi-Cal is not paying for the prescription. You, the Medicare recipient, are still responsible for paying for the prescription and processing fee.

    What is this "small processing fee"  for? How much is it?

    The processing fee is intended to cover the cost of processing charges incurred by the pharmacy. These charges occur when the pharmacy contacts Medi-Cal for the prescription pricing information. Prior to the implementation of this new prescription drug program, these processing charges were not incurred by a pharmacy when filling a prescription for a Medicare recipient. The amount of the fee is 15 cents for each prescription filled.

    Who is eligible?

    Anyone who has a Medicare card is eligible. That includes seniors over age 65 and those under age 65 who are disabled and have a Medicare card. You do not have to be on Medi-Cal.

    Do I have to fill out any forms to take advantage of the program?

    There are no forms to fill out. If you are already a Medicare recipient, and have a Medicare card in your possession, this is all you need to take advantage of this program.

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    How does it work? What do I have to do to use the program?

    When you have a prescription filled, show the pharmacy staff your Medicare card at the time you give them the prescription. If the prescription is being phoned in by a physician's office, ask the office to notify the pharmacy that you are a Medicare patient and then present your card at the time you pick-up your prescription. It is also a good idea to contact your regular pharmacy and have the pharmacy note on your record for future prescriptions, that you are a Medicare recipient.

    What drugs are covered?

    Virtually every prescription medication is covered. There is no restricted formulary and there is no prior authorization. However, over-the-counter drugs are not covered under this program.

    Can I go to any pharmacy I want to get the Medi-Cal price?

    Only Medi-Cal pharmacy providers are required to charge a Medicare recipient the Medi-Cal prescription rate. The vast majority of pharmacies in California (over 5000 pharmacies throughout California) participate in the Medi-Cal program. You may want to ask you pharmacy if they are a Medi-Cal provider. Additionally, a non-Medi-Cal pharmacy may be willing to charge a similar prescription rate.

    How much money will I have to pay?

    What you pay will depend on the medication. The price you pay will be, at most, the same price that Medi-Cal pays a pharmacy for the same medication.

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    How much will I save?

    Again, how much you save will depend on the medication. There is no specific discount from retail prices. It will depend on which drug it is, who the manufacturer is, and the quantity. In some instances, there will be large savings and in other cases the savings will be small.

    How do I know I'm getting charged the right amount?

    You can ask the pharmacy for a copy of the price inquiry information sent back to the pharmacy by Medi-Cal. Most pharmacies utilize a computer when filling a prescription. The pricing inquiries sent to Medi-Cal will be sent through these same computers. The pharmacy should be able to do what is called a "screen print" of the information sent back by Medi-Cal. 

    IT IS IMPORTANT that you make this request before your prescription is filled. This can be done when handing a prescription to the pharmacy staff or by phone if the prescription is being called in by a physician's office.

    I have called four (4) different pharmacies and have received 4 different prices, why is that?

    Prescription pricing can vary from pharmacy to pharmacy under this new program. Most of the time this will occur because there is more than one manufacturer of the drug that you are prescribed. The price may change from pharmacy to pharmacy because prices differ from manufacturer to manufacturer and pharmacies do not necessarily stock the same manufacturer of that drug. Therefore, when asking a pharmacy for a Medi-Cal reimbursement rate, it is just as important to know the manufacturer of the drug as it is to know the drug name, dosage, strength, and quantity being dispensed.  

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    I just refilled my prescription, and it costs more than last time, why? 

    The prescription drug manufacturers raise their prices periodically. The price increases occur throughout the year and for some drugs many times during the year. Medi-Cal updates the prices in their computer on a monthly basis. If your prescription price does increase, you can ask your pharmacist if the manufacturer has increased the price.

    What if I already have prescription coverage, will this new program affect it?

    You should continue to use your current insurance coverage if it is more advantageous to do so. This new program should not affect your current prescription coverage. The new program is intended for those prescriptions whose entire cost is paid by the Medicare recipient.

    For example:

    • If you have reached your yearly or monthly prescription limitation under your insurance program, and now have to pay for your prescriptions, you may want to use this new program.
    • If your prescription insurance coverage doesn't cover a certain prescription drug, you may want to use this new program.
    • If you have a deductible to meet before your coverage begins, you may want to use this new program.

    Will this program affect my Medicare coverage?

    No, this program does not affect your coverage under the Medicare program.

     

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    Who can I call if I need more information about the program?

    If you have general questions regarding the prescription drug discount program, you can contact you local Health Insurance Counseling and Advocacy Program, also known as HICAP, at 1-800-434-0222.

    Who can I call if I suspect that my pharmacy is not charging me the correct price?

    If you believe that your pharmacy is not charging the correct Medi-Cal rate as required by law, and you would like to discuss filing a complaint, you can contact the Department of Health Care Services by email at pharbene@dhcs.ca.gov.