CareAdvantage Cal MediConnect Plan (Medicare-Medicaid Plan)

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 on the CareAdvantage CMC 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

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 this form, but we will also accept any request that is written and signed by your doctor.

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.

Learn more about submitting an appeal.

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.

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 Unit

Toll free: 1-866-880-0606 Local: 650-616-2174
TTY: 1-800-735-2929 or dial 7-1-1

Call center hours: Monday–Sunday 8:00 a.m. to 8:00 p.m.


CareAdvantage Cal MediConnect Plan (Medicare-Medicaid Plan) 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 CMC 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). (Download this statement in multiple languages.)

H7885_MMP_15129_01_18_EN Approved

Page updated August 14, 2018