1. 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 Treatment Authorization Request (TAR) to ask Medi-Cal for permission to fill your prescription. It usually takes 24-48 hours for Medi-Cal to process a TAR. Ask the pharmacist to talk with your doctor about the 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 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.
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 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.
4. 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 Treatment Authorization Request (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?
No, that is not true. Diabetic supplies such as test strips, lancets and syringes are covered Medi-Cal benefits 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. 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 (TAR) may need to be completed by the pharmacy before you will be allowed to receive the brand name.
7. 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 Treatment Authorization Request (TAR) to ask Medi-Cal for approval to fill your prescription.
8. Are OTC cough and cold products covered?
Effective March 1, 2012, the California law no longer covers over-the-counter cough and cold products as a benefit of the Medi-Cal program, except for beneficiaries under 21 years of age eligible for Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program.
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 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 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 called the “Medi-Cal Contract Drug List” (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 not listed on the CDL require prior authorization from Medi-Cal. The pharmacy submits to Medi-Cal a Treatment Authorization Request (TAR) to get Medi-Cal approval. 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 may be required.
15. Can a “retroactive” Treatment Authorization Request (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. 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.