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.
For more information:
- Visit the Medi-Cal Rx website.
- Call the Medi-Cal Rx Customer Service Center at 800-977-2273.
Bring your Medi-Cal Rx Beneficiary Identification Card (BIC) when you get medications through Medi-Cal Rx.
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).
- You can also 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 Evidence of Coverage (Member Handbook) for details. Copays may change on Jan. 1 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.
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.
Filling your prescription
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.
To get information about filling your prescriptions by mail, call our partner, Birdi™ (MedImpact's mail-order pharmacy service) at 855-873-8739 (TTY: 711) or email Birdi at [email protected]. Register online at www.medimpact.com to get started.
The Medication Therapy Management (MTM) Program is an additional service that is available at no cost to eligible TotalCare members with certain medical conditions. This service is provided by MedImpact, on behalf of TotalCare. This program helps you and your doctor make sure that your medications are safe and working well. You can learn more on the MTM Program page.
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.
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 their website.
You can also ask MedImpact for a Part D Coverage Determination Form. You can send this form to MedImpact by mail or fax:
10181 Scripps Gateway Court
San Diego, CA 92131
Fax: 858-790-7100
By law, there are categories of drugs that TotalCare and Medi-Cal Rx cannot cover. You can still get drugs that are not covered, but you will have to pay the full cost yourself.
Opioids are a group of medications that doctors may prescribe to help you manage pain. They can help for a short time, but using them for a long time can be risky. If you are taking or considering taking opioids for more than three months, it’s important to know about possible side effects and safer options. You can learn more on our Opioid Information page.
If you are a new member and are taking a prescription drug that is not in our Formulary (list of covered drugs), you will need to follow our medication transition process. Learn about your options for this process in this section. You can also read our Transition Policy.
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.
It is important to safely get rid of any unwanted or expired medicines and sharps like these:
- Hypodermic needle.
- Pen needles.
- Pre-loaded sharps.
- Auto-injectors.
- Intravenous needles.
- Lancets.
- Other devices used to pierce the skin for drawing blood or for the delivery of medications.
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:
Mariposa County
Merced County
- Medication drop-off sites for Merced County
- Sharps drop-off sites for Merced County
- Merced County Department of Public Health
Monterey County
- Medication drop-off sites for Monterey County
- Sharps drop-off sites for Monterey County
- County of Monterey Health Department
San Benito County
Santa Cruz County
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.
We are here to help you.
You can speak to a Member Services Representative by calling 833-530-9015 or contact a sales agent by calling 833-530-9361
Contact Member Services
- Monday through Friday, 8 a.m. to 8 p.m.
- Phone: 833-530-9015
- Deaf and Hard of Hearing Assistance
TTY: 800-735-2929 (Dial 711) - Nurse Advice Line
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