Pharmacy

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):

Infertility Drugs/ Treatments/ Services

The following drugs/classes of drugs, or their medical uses, are excluded from coverage:
(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)

Drugs for treatment of Erectile Dysfunction

The following drugs/classes of drugs, or their medical uses, may be excluded from coverage:(K) Agents when used for the treatment of sexual or erectile dysfunction.

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

Investigational Therapies

Experimental services are not covered through Medi-Cal per the California Code of Regulations (CCR), Title 22, Section 51303(g).

Citation & Source
Title 22, California Code of Regulations, Section 51303 (h)

Examples

Unapproved, unstudied indications
Drugs that have not yet received FDA approval

Cosmetic or Hair Growth

Agents when used for cosmetic purposes or hair growth are specifically excluded from coverage.

Citation & Source
State plan under Title XIX, Social Security Act, Section 1927(d)(2), Attachment 3.1.A.1

Examples

Rogaine
Tretinoin for wrinkles

Medical Foods, Herbal Products, Dietary Supplements

Prescriptions for drugs and medicines which have not been approved for marketing by the FDA. These products typically have the following disclaimers on the label: “This product has not been evaluated by the FDA for safety, purity & efficacy” &/or “This product is not intended to diagnose, treat, cure or prevent any disease”
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

Medicare-D Covered Drugs (members with Medicare)

Effective January 1, 2006, the Medicaid agency will not cover any Part D drug for full-benefit dual eligible individuals who are entitled to receive Medicare benefits under Part A or Part B.
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.

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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).

Posted on June 17th, 2015 and last modified on November 18th, 2016.