Medication Costs

Premiums

CareAdvantage members do not pay monthly premiums because the Medicare Part B premium is covered by the Medi-Cal program.

Co-payments

Prescription drug co-pays range from:

• $0, $1.60 or $4.90 for generic drugs
• $0, $4.80 or $12.15 for brand-name drugs

The amount of your co-pay will depend on:

• Whether you get a generic or brand-name medication
• Your income
• Whether you qualify for the Extra Help with Medicare Prescriptions Program
• How much you and HPSM have already paid in the current year for your prescriptions

There is no co-payment for:

• Over-the-counter medications covered by CareAdvantage
• Medi-Cal Rx covered medications

Extra Help

Because you are eligible for Medi-Cal, you get “Extra Help” from Medicare to help pay for your Medicare Part D prescription drugs. Extra Help is a Medicare program that helps people with limited incomes and resources reduce Medicare Part D prescription drug costs, such as premiums, deductibles, and copays. Extra Help is also called the “Low-Income Subsidy,” or “LIS.”

Sometimes, the Medicare system does not have the right information about your income and resources. This may cause your prescription claims to deny at the pharmacy or your copays to be higher than they should be. If this happens, you can call the CareAdvantage Unit and provide evidence of low-income status (e.g., Medicaid card, print out from the State electronic enrollment file showing Medicaid status, etc.) so that we can update our system with the right information.

Prescription reimbursements

If you pay the full cost of a prescription, CareAdvantage will reimburse you under certain circumstances, such as when you:

• Fill a prescription in an emergency situation at a non-network pharmacy
• Need a specialized drug that is not available at a network pharmacy
• Need a drug that is only available, by law, at specific pharmacies

Note that HPSM will not reimburse you for your Part D prescription co-pay.

To request reimbursement

Prescription reimbursement requests for CareAdvantage covered drugs and items should be submitted within 1 year (365 days). To request a prescription reimbursement, send us your bill and proof of any payment you have made. (Proof of payment can be a copy of the check you wrote or a receipt from the provider.) Mail these items to:

For information regarding prescription reimbursement requests for Medi-Cal Rx covered over-the-counter drugs 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.