Medicine Coverage Determination

As your health plan, HPSM makes decisions about your benefits, medicine coverage and how much we will pay for your medical services and medicines. These are called coverage determinations or coverage decisions.

You or your doctor can request a coverage decision about your prescription medicine coverage when you want us to:

• Approve a medicine that is not in the CareAdvantage Formulary
• Waive our restriction on a medicine you want
• Reimburse you for a medicine you have already paid for
• Approve a brand-name version of a medicine rather than the generic version

For information regarding coverage decisions related to Medi-Cal Rx covered over-the-counter (OTC) medications 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.

How to Request a Coverage Decision

You or your doctor can request a coverage decision (coverage determination) about your prescription medicine coverage by phone, in person or in writing. 

Your doctor will need to send HPSM a written statement supporting your request. They can use the CareAdvantage Determination Request form, but we will also accept any request that is written and signed by your doctor.

For coverage decisions related to over-the-counter and certain vitamins covered through Medi-Cal Rx, your doctor will need to send a written statement supporting your request to Magellan. Magellan is the contractor that administers the pharmacy benefits under Medi-Cal Rx.

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.

You can submit an appeal by calling our Grievance and Appeals Unit:
1-888-576-7227 or 650-616-2850
Hours: Monday–Friday 8:00 a.m. to 5:00 p.m.
TTY: 1-800-735-2929 or dial 7-1-1

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.

For appeals related to Medi-Cal Rx, your doctor must submit the appeals request to Magellan.

If You Need an Answer within 24 Hours

Call the CareAdvantage Unit to express your specific concern or ask for a change in coverage.