Pharmacy Benefits Frequently Asked Questions
My pharmacy told me that Medi-Cal does not cover my medication. What should I do?
Some medications may require the pharmacy to submit a Prior Authorization (PA) to ask Medi-Cal Rx for permission to fill your prescription. It usually takes 24 hours for Medi-Cal Rx to process a PA. Ask the pharmacist to talk with your doctor about the medication.
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 Rx to get approval to dispense medications 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 meet your current needs.
Can I get my medications early if I am going on vacation?
Medi-Cal does not allow for early refills of your medications unless it’s medically necessary. You should work with your pharmacy and physician to either increase the amount dispensed if you know you will be going on vacation, or to have medication delivered to you while you are on vacation.
Do I have to be a Costco member to get my Medi-Cal Rx prescription filled at the Costco pharmacy?
According to Costco, a membership is not required to get prescriptions filled. Please see the Costco website for more information.
Why can I only get 30 pills if my prescription is for 60?
Some medications have restrictions on how much can be dispensed at a time. If your prescription is for more than the restricted amount, the pharmacy can submit a Prior Authorization (PA) to ask Medi-Cal Rx for permission to give you a higher amount.
My Pharmacy told me my diabetic supplies are not covered. Is that true?
No, that is not true. Specific diabetic supplies are covered Medi-Cal benefits and can only be obtained through a pharmacy. Covered diabetic supplies include diabetic blood and urine test strips, lancets, some meters and their accessories, insulin syringes, alcohol prep pads, continuous glucose monitoring (CGM) systems, and disposable insulin delivery devices (DIDD). Some restrictions apply for coverage. Information about these covered items are available on the Medi-Cal Rx website. Ask your pharmacy to call Medi-Cal Rx Customer Service Center (CSC) at (800) 977-2273 if they require additional assistance billing Medi-Cal Rx for your diabetic supplies.
Can I get the brand name 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 brand name drug if a generic is not available or if your doctor considers the brand name to be medically necessary. In cases where your doctor would like you to have the brand name when a generic is available, a Prior Authorization (PA) may need to be completed by the pharmacy before you will be allowed to receive the brand name.
Are over-the-counter (OTC) medications covered?
Only certain OTC medications may be covered with a prescription. Some OTC medications may require the pharmacy to submit a Prior Authorization (PA) to ask Medi-Cal Rx for approval to fill your prescription.
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 Rx for prior authorization to dispense medication early.
I am covered by Medicare and Medi-Cal. Why is Medi-Cal not paying for my prescriptions?
Once a Medi-Cal beneficiary is entitled to receive Medicare, Medicare Part D will cover most prescriptions. Medi-Cal 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 (800) Medicare or (800) 633-4227.
Does Medi-Cal cover Viagra?
No. Medi-Cal does not cover any drugs for sexual or erectile dysfunction.
Does Medicaid cover smoking cessation products? (e.g. Chantix, Zyban and nicotine replacement therapy)
Yes. Medi-Cal pays for smoking cessation products. In addition, the Smokers’ Helpline at (800) NO BUTTS ((800) 662-8887) is a free program available to all Californians including Medi-Cal beneficiaries.
Does Medi-Cal have a formulary?
Yes, Medi-Cal has a formulary called the “Medi-Cal Rx Contract Drugs List” (CDL). Drugs on this list generally do not require prior authorization. Drugs not on the CDL require prior authorization. The CDL can be found on the Medi-Cal Rx forms and information page. Select Covered Product Lists on the left hand side. Updates are made to the list on a monthly basis. Medications are listed by their generic name.
Outpatient disposable medical supplies, enteral nutrition formula, physician administered drugs, and durable medical equipment (DME) can be covered Medi-Cal pharmacy benefits. Medi-Cal maintains formularies of covered benefits on the Medi-Cal Rx website under Providers and Partners/Pharmacy Benefits/Covered Products Lists or on the Medi-Cal.ca.gov website/Pharmacy Manual under Durable Medical Equipment, Medical Supplies, or Incontinence Medical Supplies. Specific coverage criteria and utilization controls apply to most benefits and are defined within the formularies
What drugs require Prior Authorization (PA)?
All drugs not listed on the CDL require prior authorization. The prescriber or pharmacy submits to Medi-Cal Rx a Prior Authorization (PA) to get Medi-Cal approval.
Can a “retroactive” Prior Authorization (PA) be obtained for a previously filled prescription?
Retroactive PA requests can be submitted and will be reviewed based on applicable prior authorization rules and policies at the time the service was rendered. In addition, all applicable claim timeliness limits will be in force if the PA is approved.
Does Medi-Cal cover medical marijuana?
No, Medi-Cal must follow the federal law that classifies marijuana as an illegal Schedule I (Class I) Drug or Substance.
For Additional Pharmacy Information
Please find additional member's FAQ's here.
You can call the Medi-Cal Rx Customer Service Center (CSC) at (800) 977-2273, which is available 24 hours a day, 7 days a week, 365 days per year.
