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Drug Coverage Overview
CareAdvantage will cover only drugs that are prescribed from your doctor.
List of Covered Drugs* (CareAdvantage Formulary)
Formulary may change throughout the calendar year. Updates will be mailed to affected members,
and under the Updates Tab.
CareAdvantage Formulary Changes
Check the notices for updates to the list.
- Drugs that have been added or taken off the list
- Brand drugs that have been replaced with a generic drug
- A restriction for coverage has been added or removed
Your drug is on the CareAdvantage Formulary (list of covered drugs).
Exceptions: you can ask CareAdvantage to cover a drug that is not on the formulary, for information on how to do this,
see pages 84 - 86 in the Evidence of Coverage.
Prescriptions are from a doctor, specialist, or hospital in the CareAdvantge provider network.
Exceptions: under certain situations, prescriptions from out-of-network providers will be covered,
see page 78 in the Evidence of Coverage for more information.
You fill your prescription at a CareAdvantage network pharmacy.
Exceptions: In certain situations your prescription can be covered when using a pharmacy outside of the network,
see page 80 in the Evidence of Coverage for more information.
Some drugs on the formulary need pre-approval.
Certain drugs on the formulary need to be approved for coverage before CareAdvantage will cover the cost.
Without pre-approval, you might have to pay the full cost of these prescriptions. See page 82 in the Evidence of Coverage for more information.
CareAdvantage Drug Coverage Restrictions
Drugs that require pre-approval for coverage (prior authorization)
Some drugs in the formulary need to be approved for coverage before you fill a prescription. The table in the above link shows the drugs that need pre-approval.
It also describes the required conditions for approval, for each drug.
Drugs with quantity limits (limit on amount of tablets, number of refills)
These are drugs that are covered with a set limit on the amount of pills per prescription.
Drugs with step therapy requirements (try a different drug first)
Some drugs are covered only after you have a tried a recommended drug, but it did not work. When there are two drugs for your condition,
CareAdvantage may require you to try one drug first before covering the other drug.
Parts B and Part D
You are covered for drugs paid under Medicare part B and part D. These are the types of drugs
covered by these benefits.
- Generic and brand name drugs, and drugs given while hospitalized or in a skilled nursing facility,
are covered by Medicare Part D.
- Drugs given by injection at a doctor’s office, hospital, and dialysis facility, or that you give
yourself at home using durable medical equipment are covered by Medicare Part B. For a list of other
drugs included under Part B, see page 77 in the
Evidence of Coverage.
Services Not Covered by CareAdvantage
By law there are categories of drugs that Medicare Part B and Part D, and Medi-Cal, cannot cover.
You can still get drugs that are not covered, but CareAdvantage will not pay for them. You must
pay for the full cost of drugs not covered.
For a description of drugs not covered, see page 74 in the
Evidence of Coverage.
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