HPSM Medi-Cal
Prescription Benefits
Covered Drugs:
- Brand and generic drugs in the Medi-Cal Formulary that are prescribed by a licensed medical practitioner, including:
- Stop smoking patch or gum
- Prenatal vitamins
- Birth control
- Some over-the-counter medicines may be covered if you have a doctor’s prescription
- Non-formulary drugs that your doctor prescribes and gets prior authorization from HPSM
- Before covering some medications, HPSM may require that you try a “Step 1” medication.
Not covered
- Over-the-counter drugs
- Experimental medicines
Cost
Co-pays
- Pharmacies may charge a $1 co-pay for some prescription drugs
- Most HPSM pharmacies do not charge HPSM members any co-pays
- Both generic and brand-name drugs prescribed by your doctor are covered by the plan
Check with your provider or pharmacy to see whether you will be charged a $1 co-pay for medications you receive.
Search for a covered drug
Formulary Changes
See the list of drugs that were added, removed or updated in the Medi-Cal Formulary.
See the Nutritional Supplements for Medical Conditions that we may cover.
Pharmacy Network
Filling prescriptions
In general, your prescriptions are covered only if they are filled at HPSM network pharmacies.
If your prescription is denied at the pharmacy, call your doctor. Your doctor needs to request a prior authorization from HPSM to get coverage for that drug by filling out the Pharmacy Prior Authorization Request Form and faxing it to 650-829-2045. Your physician’s approval is required.
Search for a pharmacy
- Search by pharmacy name, health plan, location or type of provider
- Click on a pharmacy name in the search results to see additional information
- Search results include links to interactive maps and directions
- Print or save the information for individual pharmacies
- Weekly updates ensure you get the most accurate results
Pharmacies outside your area
The HPSM pharmacy network includes chains that have pharmacies outside of the San Mateo County area, which you can use when traveling in the United States.
- 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 medications
If you have been prescribed medicine for treatment of a chronic condition, a regular pharmacy may not be able to fill your prescription. Alphascript is HPSM's preferred pharmacy for specialty medications.
To find out if you need to use Alphascript:
Call Member Services, your doctor, or Alphascript. To avoid delays in filling your prescription, call Alphascript on the day that you receive your prescription (before you leave your doctor’s office or clinic, if possible).
Call Alphascript at 1-800-780-3584
Conditions that are treated with specialty medications:
- 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 medications (insulin is not included).