Medications/Drugs

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Questions




If you have questions or need help with your health care, please call our Customer Service Department at:

1-855-705-8823 (toll free)

24 hours a day/ 7 days a week.

Members with hearing or speech impairments can call our TDD/TTY line at 1-800-735-2929.

We also provide interpreter services at no cost to our members.

We have staff who speak your language.

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What is Medicare Part D?

Medicare Part D coverage is a federal program that helps pay for prescription medication. Under OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan), your pharmacy benefits are covered with small co-payments for generic and brand-name drugs, until your total yearly out-of-pocket drug costs reach $5,000 for 2018.

Formularies And Drug Information

A formulary is a list of drugs covered by OneCare Connect. After you pay your co-payment, we will pay for drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other plan rules are followed. Some medications require approval before you can receive them. This is called “prior authorization.” And in some cases, OneCare Connect requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This is called “step therapy.”

Formulary Changes

Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same co-pay for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. To get updated information about the drugs covered by OneCare Connect, please visit www.caloptima.org/onecareconnect or call Customer Service.

Prescription Drugs Transition And Exceptions

New OneCare Connect members may be taking drugs not on our formulary or subject to certain restrictions. Members should talk to their primary care provider (PCP) to decide if they can switch to an appropriate drug we cover or request an exception. Current OneCare Connect members may also request an exception if their PCP prescribes a drug not covered.

To file a complaint with Medicare, click on the following link to complete a complaint form on the Medicare website: Medicare Complaint Form.

H8016_19MM027_M Accepted (09/25/18)

OneCare Connect Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Limitations, co-pays, and restrictions may apply. For more information, call OneCare Connect Customer Service or read the OneCare Connect Member Handbook. Benefits and/or copayments may change on January 1 of each year. Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details. Other Pharmacies/Physicians/Providers are available in our network. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. OneCare Connect complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. You can get this information for free in other languages. Call toll-free 1-855-705-8823. TDD/TTY users can call 1-800-735-2929. The call is free.

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