Medicine Coverage

CareAdvantage covers brand and generic medicines that are filled by network pharmacies. However, there are certain circumstances under which CareAdvantage will reimburse you for prescriptions filled by out-of-network pharmacies.

Other medicines, such as some over-the-counter (OTC) medicines that are not covered by CareAdvantage and certain vitamins, may be covered under Medi-Cal Rx. Please visit the Medi-Cal Rx website (www.medicalrx.ca.gov) for more information. You can also call the Medi-Cal Rx Customer Service Center at 1-800-977-2273. Please bring your Medi-Cal Rx Beneficiary Identification Card (BIC) when getting medicines through Medi-Cal Rx. 

Medicine Coverage Limitations

Prior Authorization Criteria (PA)

These medicines are in the CareAdvantage Formulary but need to be pre-approved before you fill a prescription. This also includes the criteria for approval of each medicine.

Step Therapy Criteria (ST)

Some medicines are covered only after you have a tried a recommended medicine, but it did not work. When there are two medicines for your condition, CareAdvantage may require you to try one medicine first before covering the other medicine.

Formulary exceptions

CareAdvantage has rules about who is eligible to get which medicines. For example:

• CareAdvantage may cover the medicine your doctor prescribed, but you may not meet the coverage criteria.
• CareAdvantage may no longer cover a medicine you have been taking due to a formulary change.

CareAdvantage sometimes makes exceptions to the rules if the prescribing doctor shows there is a medical reason that a person needs a particular medicine. This is called a formulary exception.

Request a formulary exception

To request a formulary exception, your doctor should contact HPSM Pharmacy Services at 650-616-2088, then fax a written statement to 650-829-2045 that explains the medical reason for this request.

Medicines Not Covered

By law, there are categories of medicines that CareAdvantage and Medi-Cal Rx cannot cover. You can still get medicines that are not covered, but CareAdvantage and Medi-Cal Rx will not pay for them. You must pay for the full cost of medicines not covered.

Download the list of covered medicines (formulary)

Other medicines, such as some over-the-counter (OTC) medicines that are not covered by CareAdvantage and certain vitamins may be covered under Medi-Cal Rx. Please visit the Medi-Cal Rx website for more information. You can also call the Medi-Cal Rx Customer Service Center at 1-800-977-2273. Please bring your Medi-Cal Rx Beneficiary Identification Card (BIC) when getting medicines through Medi-Cal Rx.