Pharmacy Benefits Frequently Asked Questions
1. How much should I be charged for my prescription medications?
The pharmacy is allowed to ask for a $1 copay, however, if you cannot afford it, you are not required to pay it in order to obtain your medication.
2. Can I get my medication early?
Early refills are covered when there is an increase in dosage, if a beneficiary is going into or leaving a nursing home, or if the medications are lost or stolen. The pharmacy may have to contact Medi-Cal to get approval to dispense medication early. Beneficiaries may receive up to a 100-day supply of many medications. If you often run out of medication, contact your doctor and discuss adjusting your prescription to your current needs.
3. Can I get my medications early if I am going on vacation?
Medi-Cal does not allow for early refills of your medications unless medically necessary. You need to work with your pharmacy and physician to either increase the amount dispensed, when you know you will be going on vacation or to have medication delivered to you while you are on vacation.
4. Why can I only get 30 pills if my prescription is for 60?
Some medications are restricted. If your prescription is for more than the restricted amount, the pharmacy can submit a Treatment Authorization Request or TAR to ask Medi-Cal for permission to give you a higher amount.
5. My Pharmacy told me my diabetic supplies are not covered. Is that true?
Diabetic supplies such as test strips, lancets and syringes are covered and can only be obtained through a pharmacy. Ask your pharmacy to call 1-800-541-5555 (outside of California, please call 916-636-1980) if they require additional assistance billing Medi-Cal for your diabetic supplies.
6. My pharmacy told me that Medi-Cal does not cover my medication. What should I do?
Some medications may require that the pharmacy submit a Treatment Authorization Request or TAR to ask Medi-Cal for permission to fill your prescription. It usually takes 24-48 hours for Medi-Cal to process a TAR.
7. Can I get the name brand medication when a generic is available?
Generic drugs are safe and effective, contain the same active ingredient and work the same way as the brand name. Medi-Cal can pay for a name brand drug if a generic is not available or if your doctor considers the name brand to be medically necessary. In cases where your doctor would like you to have the brand name when a generic is available, a Treatment Authorization Request may need to be completed by the pharmacy before you will be allowed to receive the brand name.
8. Are over-the-counter (OTC) medications covered?
Any OTC medication requires a prescription.
9. Can I request an early refill if my medication was lost or stolen?
Medi-Cal will cover lost, stolen or damaged medications. The pharmacy may have to contact Medi-Cal for authorization to dispense medication early.
10. I am covered by Medicare and Medi-Cal. Why is Medi-Cal not paying for my prescriptions?
Once a Medi-Cal client is entitled to receive Medicare, Medicare Part D will cover most of your prescriptions. Medicaid will only pay for a few medications that are excluded by your Part D plan. If you need assistance to find and enroll on a Part D plan, please call 1-800-Medicare or 1-800-633-4227.
11. Does Medi-Cal cover Viagra?
No. Medi-Cal does not cover any drugs for sexual or erectile dysfunction.
12. Does Medicaid cover smoking cessation products? (e.g. Chantix, Zyban and nicotine replacement therapy)
Medi-Cal pays for smoking cessation products when used in conjunction with behavioral modification support. Some products require the pharmacy to contact Medi-Cal for authorization. The Smokers’ Helpline at 1-800-NO BUTTS (1-800-662-8887) is a free program available to all Californians including Medi-Cal beneficiaries.
13. Does Medi-Cal have a formulary?
Yes, Medi-Cal has a formulary that is call the “Medi-Cal List of Contract Drugs” (CDL). Drugs on this list generally do not require prior authorization; drugs not on the list require prior authorization (see question #14). The list can be found on the Medi-Cal website under Providers and Partners/Pharmacy Benefits/Contract Drug List. Updates are made to the list on a monthly basis. Medications are listed by their generic name.
14. What drugs require Prior Authorization (PA)?
All drugs that are not listed the CDL require a Treatment Authorization Request (TAR). Also if a drug is being used beyond a restriction listed on the CDL or it is the 7th or more prescription in a month, a TAR is usually required.
15. Can a “retroactive” TAR be obtained for a previously filled prescription?
Retroactive TAR requests can be submitted if they are requested within 180 days of the recipient’s eligibility award date. These requests can be approved back to the recipient’s eligibility effective date.
16. Why are some cough and cold products covered and some non-covered?
Cough and cold products are an optional coverage class according to the federal law. Medi-Cal covers only cough and cold products that have been approved by the FDA to be safe and effective. On March 24, 2011, legislation was passed in California eliminating over-the-counter (OTC) cough and cold products as a covered pharmacy benefit. As a result of this legislation, effective March 1, 2012, over-the-counter cough/cold products are not a benefit of the Medi-Cal program. Early Periodic Screening, Diagnosis, and Treatment (EPSDT) eligible beneficiaries are exempt from this elimination of benefit.
For Additional Pharmacy Information
- For claims or medication issues, contact Xerox State Healthcare, LLC at (800) 541-5555 (outside of California, please call 916-636-1980). The Telephone Service Center (TSC) is available 8 a.m. to 5 p.m., Monday through Friday, except holidays
- For CDL Issues, contact Pharmacy Benefits Division at (916) 552-9500
- For rebate issues, contact Pharmacy Benefits Division at (916) 552-9500