HPSM Medi-Cal
Prescriptions & Pharmacies
Covered drugs
- Brand and generic drugs on the Medi-Cal Formulary (preferred drug list) that are prescribed by a licensed doctor or other health cared provider
- Some over-the-counter medicines may be covered if you have a doctor’s prescription
- Drugs not on HPSM’s Formulary that are covered only after your doctor gets a pre-approval (prior authorization) from HPSM
- Before covering some drugs, HPSM may require that you try a “Step 1” drug
Not covered
- Drugs that are still being tested and/or have not been approved by the Food and Drug Administration (FDA)
- Drugs that are covered by the Medi-Cal Fee-for-Service (FFS) program (“carved-out” drugs)
- Drugs used for cosmetic reasons, erectile dysfunction, fertility or hair loss
Cost
Co-pays
- Pharmacies in HPSM’s network may charge a $1 co-pay for some prescription drugs
- Most pharmacies do not charge HPSM members any co-pays: ask your doctor or pharmacy if you will be charged
- Both generic and brand-name drugs prescribed by your doctor are covered
- Note: Not every brand name drug has a generic equivalent (equal), but if it is available, the use of the generic equivalent is usually required
Search for a covered drug
Use the formulary search form to find a covered drug by generic or brand name, or view all drugs within a group
Changes to the drug list
See the list of drugs that were added, removed or changed
See the nutritional supplements for medical conditions that we may cover
Pharmacy Network
Filling prescriptions
Most of the time, your drugs are covered only if they are filled at HPSM network pharmacies.
If your prescription is denied at the pharmacy, call your doctor. Your doctor will need to ask for pre-approval from HPSM. They can do this by filling out the Pharmacy Prior Authorization Request Form and the Pharmacy Prior Authorization Request Form and faxing it to 650-829-2045.
Search for a pharmacy
The HPSM network has 234 pharmacies in San Mateo County and San Francisco
- Search by pharmacy name or location
- Click on a pharmacy name for more information
- Includes links to maps and directions
- Print or save information about pharmacies
- Weekly updates ensure you get the best results
Pharmacies outside your area
The HPSM network has pharmacy chains with stores around the country. You can use these when you go outside of San Mateo County.
- Costco: 1-800-607-6861
- CVS: 1-800-746-7287
- Target: 1-800-440-0680
- Rite Aid: 1-800-748-3243
TTY/TDD: 1-800-821-1833 - Walgreens: 1-800-925-4733
Pharmacy for specialty drugs
If you have to get a drug for a chronic health issue, you may need to go to a specialty pharmacy to be able to fill your prescription. Alphascript is HPSM's preferred pharmacy for specialty drugs.
To find out if you need to use Alphascript:
Call Member Services, your doctor or Alphascript. To avoid delays in getting your drugs, call Alphascript on the day that you get your prescription. Call before you leave your doctor’s office or clinic, if you can.
Call Alphascript at 1-800-780-3584
Health issues that are treated with specialty drugs
- HIV/AIDS
- Cancer
- Hepatitis B
- Hepatitis C
- Cystic fibrosis
- Rheumatoid arthritis
- Multiple sclerosis
- Crohn’s disease
- Kidney disease
- Organ transplant
- Psoriatic arthritis
- Ulcerative colitis
- Plaque psoriasis
- Bone marrow transplant
Many self-injectable drugs are specialty drugs (insulin is not one of them)
For more information about Medi-Cal prescriptions and pharmacies, refer to section 4 of Medi-Cal Member Handbook. To order a printed Member Handbook, email CustomerSupport@hpsm.org or call Member Services.