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Prescription and Medicare Part D Pharmacy Benefits

If you need medications to treat your illness or condition, your doctor will give you a prescription. Once you choose a network pharmacy, take your prescription there to get your medication. Your doctor may also send it to the pharmacy for you. You can search the online Pharmacy Directory to find a network pharmacy near you. Make sure the pharmacy knows about all of the medications you are taking and any allergies you have. If you have questions about your prescription, ask the pharmacist.

TotalCare covers both brand name and generic drugs when they are filled at a pharmacy in the network. Sometimes, TotalCare will reimburse you for prescriptions from pharmacies that are not in the network.

Medi-Cal Rx: Some medicines that Medicare doesn’t cover, like some over-the-counter (OTC) drugs and vitamins, might be covered by Medi-Cal Rx.

Для дополнительной информации:

Посетить Веб-сайт Medi-Cal Rx.
Call the Medi-Cal Rx Customer Service Center at 1-800-977-2273.

Bring your Medi-Cal Rx Beneficiary Identification Card (BIC) when you get medications through Medi-Cal Rx.

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List of Covered Prescription Drugs

If you need medications to treat your illness or condition, your doctor will give you a prescription. If you have questions about your prescription, make sure to ask the pharmacist. They are there to help you.

There are three ways to find out which drugs are covered:

You can search for a covered drug by generic or brand name or by category in our List of Covered Drugs (Formulary).
Вы также можете download a copy of the Formulary.
You can also call Member Services and ask them to mail one to you.

Copays for your prescription drugs may vary based on the level of Extra Help you get from Medi-Cal. Please see your Доказательство покрытия (Справочник участника) for details. Copays may change on January 1st of each year.

TotalCare covers brand and generic drugs that are filled by network pharmacies. To find a network pharmacy near you, search our online Pharmacy Directory.

Найти аптеку

If you are filling or refilling a prescription, you must use a pharmacy that works with TotalCare or Medi-Cal Rx. To find a network pharmacy near you, use the online Pharmacy Directory.

Note: In the downloadable and printed versions of the pharmacy directory, you’ll also see a list of providers. The Pharmacy and Provider lists are in the same document.

Выполнение вашего рецепта

When you go to the pharmacy, make sure to bring:

Your TotalCare Member ID card.
Your Medi-Cal Benefits Identification Card (BIC).

The pharmacy will use these cards to find your information and give you your medications. If you get a bill for prescriptions, call TotalCare Member Services at the number listed on the bottom of the page.

You should have received your BIC when you first became eligible for Medi-Cal benefits. There are two (2) different types of the BIC. Either one works.

Get your prescription drugs by mail

Medication Therapy Management (MTM) Program

Drug Coverage Limitations

Prior Authorization Criteria (PA): These drugs are in the TotalCare Formulary but must be approved before you can fill your prescription. This also includes the rules for when these drugs can be approved. View the list of drugs with Prior Authorization Conditions.

Step Therapy Criteria (ST): Some drugs are covered only after you have tried a different, recommended drug, but it did not work. If there are two drugs that treat your health condition, you may need to try one before TotalCare covers the other. View the list of Medications with Step Therapy Criteria.

Formulary Exceptions

TotalCare has rules about who can get certain drugs. For example:

TotalCare may cover the drug your doctor prescribed, but you may not meet the coverage criteria.
TotalCare may no longer cover a drug you have been taking due to a formulary change.

Sometimes, TotalCare makes an exception if the prescribing doctor says there is a medical reason why you need a certain medicine. This is called a “formulary exception.”

How to request a formulary exception
Your provider should contact MedImpact. Your provider will then fax or mail a written statement to MedImpact that explains the medical reason for this request.

You can ask MedImpact for a coverage determination by phone at 800-788-2949 or through их веб-сайт.

You can also ask MedImpact for a Форма определения покрытия Части D. You can send this form to MedImpact by mail or fax:
10181 Суд Скриппса Гейтвей
Сан-Диего, Калифорния 92131
Fax: 858-790-7100

Drugs Not Covered

Информация об опиоидах

Политика перехода на рецептурные препараты

Medicare Prescription Payment Program

The Medicare Prescription Payment Program is a voluntary payment option that works with your current drug coverage. It can help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). This payment option may help you manage your expenses, but it doesn’t save you money or lower your drug costs.

This payment option might not be right for you if you already get help paying for your prescription drug costs through programs like Extra Help from Medicare or a State Pharmaceutical Assistance Program (SPAP). Call TotalCare Member Services for more information.

Куда сдать лекарства и острые предметы

It is important to safely get rid of any unwanted or expired medicines and sharps like these:

Игла для подкожных инъекций.
Иглы для ручек.
Предварительно загруженные острые предметы.
Автоинжекторы.
Внутривенные иглы.
Ланцеты.
Другие устройства, используемые для прокалывания кожи с целью забора крови или доставки лекарств.

Sharps must be kept in sharps containers approved by the U.S. Food and Drug Administration. Your county has drop-off locations for both medicines and sharps:

Округ Марипоса

Округ Мерсед

Округ Монтерей

Округ Сан-Бенито

Пункты приема лекарств и острых предметов в Сан-Бенито

Округ Санта-Крус

Пункты приема лекарств в округе Санта-Крус

Potential for contract termination

If TotalCare (HMO D-SNP) terminates the plan or reduces its service area, you will have a Special Enrollment Period (SEP) to change your coverage. You may continue to have your prescriptions covered by the terminating plan for a transition period, usually until the end of the year, if your drugs are still on the formulary. You can join a new Medicare Part D plan during your SEP, which may cover your prescriptions. If you qualify for Extra Help with prescription drug costs, you will be assigned to a new Extra Help-eligible plan.

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