CareAdvantage Dual Eligible Special Needs Plan (D-SNP) 2023
Drug Coverage Determination
As your health plan, HPSM makes decisions about your benefits, drug coverage and how much we will pay for your medical services and drugs. These are called coverage determinations or coverage decisions.
You or your doctor can request a coverage decision about your prescription drug coverage when you want us to:
- Approve a drug that is not in the CareAdvantage Formulary
- Waive our restriction on a drug you want
- Reimburse you for a drug you have already paid for
- Approve a brand-name version of a drug rather than the generic version
For information regarding coverage decisions related to Medi-Cal Rx covered over-the-counter (OTC) medications and vitamins, please visit the Medi-Cal Rx website (www.medi-calrx.dhcs.ca.gov). You can also call the Medi-Cal Rx Customer Service Center at 1-800-977-2273.
How to Request a Coverage Decision
You or your doctor can request a coverage decision (coverage determination) about your prescription drug coverage by phone, in person or in writing.
Your doctor will need to send HPSM a written statement supporting your request. They can use the CareAdvantage Determination Request form, but we will also accept any request that is written and signed by your doctor.
For coverage decisions related to over-the-counter and certain vitamins covered through Medi-Cal Rx, your doctor will need to send a written statement supporting your request to Magellan. Magellan is the contractor that administers the pharmacy benefits under Medi-Cal Rx.
If You Disagree with Our Decision
If you do not agree with our coverage decision, you can submit an appeal, which is a formal request for us to review and change our coverage decision. An appeal to a plan about a Part D coverage decision is also called Coverage Redetermination.
You can submit an appeal by calling our Grievance and Appeals Unit:
1-888-576-7227 or 650-616-2850
Hours: Monday–Friday 8:00 a.m. to 5:00 p.m.
TTY: 1-800-735-2929 or dial 7-1-1
You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. You are not required, however, to hire a lawyer to ask for any kind of coverage decision or to appeal a decision.
For appeals related to Medi-Cal Rx, your doctor must submit the appeals request to Magellan.
If You Need an Answer within 24 Hours
Call the CareAdvantage Unit to express your specific concern or ask for a change in coverage.
CareAdvantage Dual Eligible Special Needs Plan (D-SNP) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Limitations and restrictions may apply. For more information, call the CareAdvantage Unit or read the CareAdvantage 2023 Member Handbook.
Benefits and co-pays may change on January 1 of each year.
If you speak other languages other than English, language assistance services, free of charge, are available to you. Call 1-866-880-0606 (TTY: 1-800-735-2929 or dial 7-1-1). ( Download this statement in multiple languages.)
Page updated October 1, 2022