Prescription Medicine Coverage

CareAdvantage members’ prescription medicine coverage is managed by HPSM. To see if your medicines are covered, use our online CareAdvantage Formulary.

As a CareAdvantage member, you pay:

• $0 premiums and deductibles
• Low or no co-payments for prescription medicines
• $0 for many over-the-counter (OTC) medicines

Understanding your CareAdvantage coverage will help you get the medicines you need to be healthy. Below are simple definitions of common healthcare benefit terms and specific details about CareAdvantage medicine coverage.

Premiums

Premiums are a monthly amount of money that some health insurance plans charge members.

As a CareAdvantage member, you do not pay any premiums. That is because the Medicare Part B premium is covered by the Medi-Cal program.

Deductibles

Deductibles are a fixed amount of money that some health insurance plans charge members for services each year before they start paying.

As a CareAdvantage member, you do not pay any deductibles. CareAdvantage pays for all covered services. 

Co-payments

Co-payments are small fees you may need to pay for prescription medicines.

CareAdvantage prescription medicine co-payments range from:

• $0, $1.60 or $4.90 for generic drugs
• $0, $4.80 or $12.15 for brand-name drugs

The amount depends on:

• Whether you get a generic or brand-name medication
• Your income
• How much you and HPSM have already paid in the current year for your prescriptions
• Whether you qualify for the Extra Help with Medicare Prescriptions Program

  There is no co-payment for OTC medicines covered by CareAdvantage and prescription medicines covered by Medi-Cal Rx. 

Over-the-counter (OTC) coverage

CareAdvantage also covers some over-the-counter (OTC) products at no cost. You may need a prescription from your doctor for some OTC products. But you can get many OTC products without a prescription or coverage decision through our OTC+ program with NationsBenefits.

Learn more about the CareAdvantage OTC benefit.

Extra Help

As a CareAdvantage member, you are eligible for Extra Help (or Low-Income Subsidy). This Medicare program helps people pay for Medicare Part D prescription medicines. In general, the lower your income is, the lower your prescription medicine co-payments are. 

Make sure Medicare has the right information about your income and resources. If they don’t, the pharmacy may deny your prescription claims or your copayments may be higher than they should be. If this happens, contact the CareAdvantage Unit. If you provide evidence of low-income status (such as a Medicaid card or printout from the State electronic enrollment file showing your Medicaid status), we can update our system.

Reimbursement

CareAdvantage covers brand and generic medications 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, such as when you:

• Fill a prescription in an emergency at a non-network pharmacy
• Need a specialized medicine that is not available at a network pharmacy
• Need a medicine that is only available, by law, at specific pharmacies

HPSM will not reimburse you for your Part D prescription co-pay.

To request reimbursement for a prescription medicine:

1. Send us your bill and proof of any payment you have made (such as a copy of the check you wrote or a receipt from the provider)
2. Mail these items to:

Prescription reimbursement requests for CareAdvantage covered medicines and items must be submitted within one year (365 days).

To request prescription reimbursement for over-the-counter products covered by Medi-Cal Rx, visit the Medi-Cal Rx website or call the Medi-Cal Rx Customer Service Center at 1-800-977-2273.

Medi-Cal Rx coverage

Your prescription medicine coverage is managed by HPSM rather than California State’s Medi-Cal Rx program. That means you:

• Use just one card for your healthcare and medicine benefits
• Call one phone number when you need help with your healthcare or medicine benefits.

Non-Medicare covered drugs, such as some over-the-counter (OTC) medications 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. When getting medications through Medi-Cal Rx, be sure to bring your Medi-Cal Rx Beneficiary Identification Card (BIC).

Learn more about Medi-Cal Rx

Durable medical equipment (DME)

DME refers to items designed to help you manage a health condition, heal from an injury, live independently and/or function in the world. Examples of DME include wheelchairs, walkers, crutches, medical beds, diabetic supplies, intravenous infusion pumps, speech generating devices, oxygen equipment, prosthetics, blood pressure monitors and glucose monitors.

CareAdvantage covers all medically necessary DME that Medicare and Medi-Cal usually pay for. If you need DME, your provider will order it for you. If HPSM’s supplier in your area does not carry a particular brand or maker, your provider may ask them if they can special order it for you.

Some DME is also covered under the CareAdvantage over-the-counter (OTC) benefit with NationsBenefits. As a CareAdvantage member, you can see a list of products you may be able to get at no cost by logging in to the MyBenefits Portal or MyBenefits app (which you can download for iPhone or Android smartphones). 

Learn more about the CareAdvantage OTC benefit.

Coverage limitations

Prior authorization criteria

These drugs 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 drug.

View the list of drugs with Prior Authorization Criteria 

Step therapy criteria

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.

View the list of medications with Step Therapy Criteria

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 medications that CareAdvantage and Medi-Cal Rx cannot cover. You can still get medications 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 drugs (formulary)

More about CareAdvantage medicine benefits and coverage