The Pharmacy and Therapeutics (P&T) Advisory Committee is responsible for developing, managing, updating, and administering the HPSJ Formulary.
The P&T Committee is comprised of primary care and specialty physicians, pharmacists, and other health care professionals. Decisions are made based on the most current medical evidence in peer-reviewed literature, safety and efficacy, pharmacoeconomics, and therapeutic need.
Carved-out and non-covered benefits
There are some medications and services that are not included or specifically excluded from the benefit. These include (but are not limited to):
(B) Agents when used to promote fertility.
Citation & Source
Evidence of Coverage Booklet
State plan under Title XIX, Social Security Act, Section 1927(d)(2)
Examples
- Clomid (clomiphene)
- Ovidrel (HCG)
- Novarel (Chorionic Gonadotropin)
Citation & Source
Erectile dysfunction (ED) drugs have not been a Medi-Cal benefit since the enactment of Assembly Bill 2885 (Chapter 95, Statutes of 2006) on July 20, 2006.
Examples
- Viagra
- Cialis
- Levitra
Citation & Source
Title 22, California Code of Regulations, Section 51303 (h)
Examples
- Unapproved, unstudied indications
- Drugs that have not yet received FDA approval
Citation & Source
State plan under Title XIX, Social Security Act, Section 1927(d)(2), Attachment 3.1.A.1
Examples
- Rogaine
- Tretinoin for wrinkles
Citation & Source
Evidence of Coverage Booklet
State plan under Title XIX, Social Security Act, Section 1927(d)(2)
Examples
- Deplin (l-methylfolate)
- Lactobacillus
- Coenzyme Q10
- Fish Oil
- Melatonin
- Glucosamine/Chondroitin
Citation & Source
State plan under Title XIX, Social Security Act, Section 1935(d)(1)
Examples
- All drugs not specifically exclude from the Medicare-D benefit
The following list of medications is carved-out from Medi-Cal managed care plans such as Health Plan of San Joaquin and should be billed directly to Medi-Cal Fee-for-Service. Click on the button to view the list.
California Children’s Services (CCS) Program
CCS is a California program for children up to 21 years old with certain health conditions. Medications used to treat these conditions are the responsibility of the CCS program and are not a part of the HPSJ Medi-Cal Pharmacy Benefit. CCS covered prescriptions include agents in the following treatment categories: cardiology, neurology, endocrinology, oncology, hematology, metabolism disorders, gastroenterology, ophthalmology, rheumatology & other connective tissue/musculoskeletal disorders, pulmonology, nephrology, immunology and severe skin/subcutaneous conditions. Disabling injuries may also be eligible for CCS services.
For coverage of medications by CCS, the member will need to see a CCS approve physician and have a prior approval through CCS known as a Service Authorization Request (SAR).