Medication: Prescriptions & Drug Coverage

As a CenCal Health Member, you have medication coverage. This drug list is called a formulary. If you would like a copy of this list, you can call our Member Services Department at our toll free telephone number at (877) 814-1861 or go to our Formulary Section. This drug list is updated several times a year to include newer drugs that have proven to be effective. Even though a medication may be listed in the formulary, there is no guarantee that your PCP or specialist will prescribe that medication for your particular medical condition. If you have questions about a particular medication, talk with your doctor. Also on this list are certain over-the-counter drugs and supplies.

These include:

  • Diabetic supplies
  • Antacids for upset stomach
  • Vitamins for pregnant women
  • Condoms
  • Treatment for yeast infections

Not all products or brands on the market are on CenCal Health’s formulary. Your Primary Care Doctor or specialist will know which ones are available. Even though you can buy some of these products without a prescription, you will need a prescription from your Primary Care Doctor if you want the Health Plan to pay for these items.

Your pharmacy benefits are limited to a maximum of 7 prescriptions per calendar month (January through December); this applies to new and refill prescriptions. Prescriptions from all pharmacies will count towards your monthly prescription limit. The 7 prescription limit does not apply to the following:

  • Antibiotics medications
  • Medications for family planning such as oral contraceptives (birth control)
  • Medications for treatment of AIDS or HIV related conditions
  • Medications for cancer treatment
  • Medications for diabetes treatment
  • Medications to suppress the immune system used for organ transplant patients
  • Newborn using mother’s identification number for the first two months of birth
  • Members living in a nursing facility (long term care)

If you go over this limit and do not meet any of the above criteria, a prior authorization will need to be submitted to CenCal Health for your prescription. Please ask your pharmacy to request a Pharmacy Authorization Form (PAF) from your doctor. The PAF must be authorized before your prescription can be filled. If you have questions regarding your pharmacy benefits, please call the Member Services Department.

ages1