REMINDER: HPSJ members cannot be charged for medications

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Date: May 29, 2018
To: HPSJ Network Pharmacies
From: HPSJ Pharmacy Department
Subject: REMINDER: HPSJ members cannot be charged for medications 
Business: Medi-Cal

This is a reminder that both the Knox Keene Health Care Service Plan Act of 1975 (H&S §1379, §1385) and California Code of Regulations (28 CCR §1300.67.8) mandate that all providers who contract with HPSJ are prohibited from charging patients for medications covered by HPSJ.

Q: What does this mean?

  • For any HPSJ members, you must always bill directly to HPSJ and cannot resort to billing the patient for cash (unless the medication is an excluded benefit) as that would be considered a surcharge towards the patient.
  • HPSJ members are never to be charged a fee for any covered benefits. Charging cash is not permitted.

Q: Can the member pay cash to cover the cost, if the claim is rejected by HPSJ?

  • NO – This is in violation of the Knox-Keene act. HPSJ will cover the medication if medically appropriate or suggest a suitable formulary alternative.  A prior authorization should be submitted to initiate the process.
  • If the member cannot wait the 24-hour turn-around time, a Three-Day Override can be used.

Q: What if HPSJ denies the prior authorization?  Can the patient pay cash for it?

  • NO – This is in violation of the Knox-Keene act. HPSJ will cover the medication if it is medically appropriate or will suggest a suitable formulary alternative.  If an alternative is suggested, the pharmacy provider may contact the provider for a prescription.
  • If the patient or provider wish to appeal the decision, please have them contact HPSJ at (209)9426320 to be directed to the appeals department.

Q: What penalties can occur if you charge an HPSJ member any fees regarding covered benefits?

  • According to your contract with HPSJ, termination from the Pharmacy Network may result from violating Federal or State regulations.

Q: What medications are considered specifically excluded benefits?

  • Medical foods, herbal products, dietary supplements, erectile dysfunction drugs, fertility drugs, cosmetics, or hair growth treatments.

Q: How do I submit a prior authorization?

  • Fill out all fields on the required PA form found at (both pages).
  • Attach all clinical information and fax all documents to (209)762-4704, or send to the member’s provider to complete.

Q: How is a 3-Day Override accomplished?

  • The 3-day override only applies to medications that require Prior Authorization, Step Therapy, or are Non-Formulary.
  • This override should only be used for emergency situations for alleviation of severe pain and/or the treatment of unforeseen medical conditions, which, if not treated immediately, would lead to disability or death.
  • The 3-Day Override Code may only be used once per drug/strength, per 365 days, and billed for only a three-day supply.  
  • Please refer to  supply for further information regarding the 3day override.

Posted on May 29th, 2018 and last modified on February 27th, 2023.