Medication Coverage

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.

CareAdvantage also covers some over-the-counter (OTC) products. Certain OTC products are covered with a prescription from your doctor while others may be available at no cost through our OTC+ program. For the OTC products that we cover under the OTC+ program, no prescription is required. In general, no coverage decision is required for the OTC products that we cover. For more information on your OTC Benefit with Nations Benefits, please visit our Over-the-counter page.

Medi-Cal Rx: 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 (www.medicalrx.ca.gov) for more information. You can also call the Medi-Cal Rx Customer Service Center at 1-800-977-2273. Please bring your Medi-Cal Rx Beneficiary Identification Card (BIC) when getting medications through Medi-Cal Rx.

Drug Coverage Limitations

Prior Authorization Criteria (PA)

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.

Step Therapy Criteria (ST)

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.

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.

Drugs 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 drugs not covered.

Download the list of covered drugs (formulary)

Other 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 (www.medicalrx.dhcs.ca.gov) for more information. You can also call the Medi-Cal Rx Customer Service Center at 1-800-977-2273. Please bring your Medi-Cal Rx Beneficiary Identification Card (BIC) when getting drugs through Medi-Cal Rx.