Medi-Cal will cover most prescriptions. In order to be covered, first, the prescription has to allow you to stay healthy or treat a medical problem.
There is a list of approved medicines that Medi-Cal will cover without further verification. If your doctor is prescribing a medication that is not on the pre-approved list, your doctor will need to provide an explanation why that specific drug is needed. It is then up to Medi-Cal to decide if it will be covered by your health plan.
Over-the-counter prenatal vitamins are also covered by Medi-Cal.
Check Your Eligibility
To get your prescriptions filled, you will need to go to a pharmacy that accepts Medi-Cal. Both your doctor and your pharmacy have to be on your Medi-Cal health plan in order for the prescriptions to be covered by your plan.
In some situations, you will need to get approval from Medi-Cal before having a prescription filled. This generally happens if you request having more than six prescriptions filled within a one-month period, the medicine is not on the approved list, or if the form of medicine prescribed is different than what is approved.
For example, your doctor may prescribe a medicine in liquid form, but the approved version is in capsule form. You will need to verify it is actually the same prescription and get authorization from Medi-Cal to get the liquid covered.
When additional approval is needed, either your doctor or your pharmacist will need to send a Treatment Authorization Request (TAR) for to Medi-Cal. It usually takes 24 hours for a request to get approved or denied.
In some cases, Medi-Cal will request additional information regarding the request from the doctor or pharmacist. However, if you do not hear back either way in 30 days, the medicine is automatically approved and covered by Medi-Cal.
Check Your Eligibility
If the medicine is something you need immediately, you can request enough medicine for 72-hours from your pharmacist while you wait for approval from Medi-Cal. You can also pay for the prescription but still request a TAR be sent. If the medication is approved after the fact, the pharmacy is required to refund your money.
If you are in a health plan, and our pharmacist refuses to submit a TAR for you, you have a couple options. First, you can contact your health plan, and they can send a TAR request to the pharmacy on your behalf. Second, you can contact your Health Plan’s Member Services Department and file a grievance against the pharmacy.
If you are not on a health plan and the pharmacist refuses to submit a TAR for you, your doctor can submit it on your behalf.
If Medi-Cal denies your request for a medication approval, you should find out why. Medi-Cal will send a letter with a written explanation why it wasn’t approved.
You should then go to your doctor with the reason why and see what other options you have in medications for your particular need. You can also appeal the denial and request a hearing during which you will have a chance to argue why the medication you are requesting is a necessity.