Calviva Health Medi-Cal Preferred Drug List
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CalViva Health Medi-Cal Preferred Drug List The CalViva Health Medi-Cal Preferred Drug List (PDL) includes drugs covered by CalViva Health. The drug list is updated each month and may change. To get the most up-to-date information or a printed copy, call Member Services at 1-888-893-1569 (TTY: 711). The latest drug list can be viewed on our website at https://www.calvivahealth.org/members-info/. It is also available on our web site in a machine readable format. Go to “Formulary List” Use the “Formulary List” link to view the list of drugs covered by CalViva Health Medi- Cal. PLEASE THROW AWAY ALL PREVIOUS VERSIONS OF THE DRUG LIST CV_Drug List Front Matter_ENGLISH_2.5.20 Table of Contents What is the CalViva Health Medi-Cal PDL?......................................................................iii How do I use the CalViva Health Medi-Cal PDL?.............................................................iii How do I find a drug in the Drug List?...............................................................................iii How are the drugs listed in the categorical list?.................................................................iv What if my drug is not on the CalViva Health Medi-Cal PDL?.......................................iv Can I go to any pharmacy?...................................................................................................v Are there any limits on my drug coverage?........................................................................v Are there limits on opioid pain drugs?................................................................v What is Morphine Milligram Equivalent (MME) Dosing?..................................v How can I get an exception to the rules for the drug coverage?......................................vi What if I’m a new member?...............................................................................................vi What are over-the-counter drugs?.....................................................................................vi Are brand name drugs covered?........................................................................................vi What is a generic drug?......................................................................................................vi Will the pharmacist give me a generic drug if one is available?.....................................vi Are there any excluded or carve-out drugs?....................................................................vi What is California Children’s Services?.........................................................................vii What about drugs I get from my doctor or in my doctor’s office?..............................vii Definitions…………………..……………………………………………………………..vii Categorical list of prescription drugs……………………………………………………..1 Alphabetical index of prescription drugs………………………………………….Index 1 ii Welcome to CalViva Health What is the CalViva Health Medi-Cal PDL? The drug list includes drugs used to treat common diseases or health problems. A team of doctors and pharmacists meet regularly to decide which drugs should be on the drug list. The team reviews current and new drugs and choose drugs that work best and are safe. This drug list is updated each month. These changes may include the form a drug comes in (i.e. tablet or capsule) or if a drug has a limit on the amount that can be filled at one time. Changes may also include if a drug requires prior authorization, step therapy, or if a drug is no longer covered on the drug list. How do I use the CalViva Health Medi-Cal PDL? Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug list. Brand name and generic drugs are listed in the index. Next to your drug, you will see the page number where you can find your drug. The table below has descriptions of the limits that may appear on the drug list: Abbreviation Term What it means AL Age Limit Some drugs are only covered for certain ages. These drugs are carved out by the Department of Health Care Services. This means these drugs are covered by the CO Carve Out Medi-Cal Fee-for-Service program and can be billed to the State by the pharmacy. F Formulary These drugs are covered on the Drug List. These drugs are not covered on the Drug List. If your NF Non-Formulary doctor feels you need a drug that is not covered, he or she can ask us to make an exception. Your doctor must ask for approval from CalViva Health PA Prior Authorization before some drugs will be covered. QL Quantity Limit Some drugs are only covered for a certain amount. These drugs are made in both prescription form and Over- RX/OTC Prescription and OTC the-counter (OTC) form. In some cases, you must first try certain drugs before CalViva Health covers another drug for your health condition. ST Step Therapy For example, if Drug A and Drug B both treat your health condition, CalViva Health may not cover Drug B unless you try Drug A first. These drugs are specialty drugs. You can only get these Specialty Pharmacy SP drugs from a specialty pharmacy. All prescriptions must Program be filled by the listed specialty pharmacy. How do I find a drug in the Drug List? You can search for a drug by using the search tool. Drugs can be found in alphabetical order or by medical condition. There are three ways to find out if your drug is covered. iii Search Tool: Open the List of Drugs (PDF). Hold down the “Control” (Ctrl) and “F” keys. When the search box appears, type the name of your drug. Press the “Enter” key. Alphabetical Index: The index at the end of the PDF lists the names of generic and brand name drugs from A to Z. Once you find a drug name, go to the page number listed to see if the drug is covered. Therapeutic Category: The drugs are grouped into categories. The categories may also be grouped by the class to which the drug is in. If you know what category your drug is in, look on the list to find the category. You can then look for your drug in that category. A drug will not be on the list if a generic equivalent for a brand name drug is not offered. A drug may not be found if it is not covered. Even though a drug is on the drug list, it does not mean that your doctor will prescribe the drug for your medical condition. How are the drugs listed in the categorical list? A drug is listed alphabetically by its brand and generic names in its category and class. The generic drug name for a brand drug is included after the brand name in parentheses in bold lowercase and italicized letters. Brand Drug Example: EPOGEN (epoetin alfa) If a generic equivalent for a brand name drug is on the list and covered, the generic drug will be on the list apart from the brand name drug. It will be in bold lowercase and italicized letters. Generic Drug Example: esomeprazole magnesium cap delayed release If a generic drug is marketed under a trademark protected brand name, the brand name will be on the list in all CAPITAL letters. It will appear after the generic name in parentheses. It will be in regular typeface with first letter of each word capitalized. Generic Drug Marketed Under A Brand Name Example: (Levothyroxine Sodium) LEVOXYL What if my drug is not on the CalViva Health Medi-Cal PDL? If your drug is not on the drug list, call Member Services at 1-888-893-1569 and ask if your drug is covered. If your drug is not on the list, you can ask your doctor if there is a drug on the list that will work the same way. If your doctor wants you to have a drug that is not on the list, your doctor can ask us to make an exception. See the section, “How can I get an exception to the rules for the drug coverage?” for more information. iv Can I go to any pharmacy? Members must use a pharmacy in the retail network. These pharmacies have a contract with CalViva Health. To find a pharmacy, call Member Services at 1-888-893-1569. Some drugs are only covered when they come from a specialty pharmacy. Specialty drugs are used to treat ongoing or complex conditions. They also may need special handling or training to ensure safe use. The specialty pharmacy will mail drugs to your home, to your work, or to another address you choose. Specialty drugs may also be sent to your doctor’s office. Specialty drugs are listed in the Requirements/Limits column on the drug list. Drugs that do not have a specialty pharmacy listed in the Requirements/Limits column on the drug list can be filled at any pharmacy in the network. You can ask for an exception to have a specialty drug filled at a retail network pharmacy if: How you take your drug has changed and you need to fill the drug right now. Your drug is going to arrive late or always arrives late. You have an urgent need for a drug and did not understand how to get the drug from the specialty pharmacy. You have an emergency and cannot wait for the drug to come from the specialty pharmacy. If you cannot use a specialty pharmacy, you can ask for an exception to get all your drugs filled at a retail network pharmacy if: You do not have a mailing address or a way to get your drugs by mail. Your doctor’s office gives the drugs to you. Using a specialty pharmacy is a hardship for you. If you need an exception, you must ask us. Your doctor or your pharmacy may also ask for an exception. To ask us for an exception, please call CalViva Health Member Services at 1-888-893- 1569 (TTY: 711). We are here 24 hours a day, seven days a week. Are there any limits on my drug coverage? Some drugs have limits on coverage. These limits are noted in the Requirements/Limits column on the drug list. Are there limits on opioid pain drugs? Prior Authorization is not required for short term use of most opioid pain drugs. You can get a 7 day supply of these drugs when your doctor orders them for you the first time.