Pharmacy

Pharmacy

formulary
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):

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)

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

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

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

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

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.

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.