Pharmacy Services

Starting January 1, 2022, Medi-Cal Pharmacy Benefits will be administered through the fee-for-service delivery system Medi-Cal Rx. If you receive  Medi-Cal health coverage through L.A. Care or a Plan Partner – Anthem Blue Cross, Blue Shield of California Promise Health Plan, or Kaiser Permanente – Please visit the DHCS Medi-Cal Rx website for more information.

On January 31, 2025 Medi-Cal Rx will require your health care team to obtain Prior Authorization (PA) for some Medi-Cal Rx drugs, enteral nutrition products and/or pharmacy supplies for members under 22 years of age. When required, your health care provider will submit the PA form to Medi-Cal Rx to request approval for your prescription.

Coverage and access to Medi-Cal pharmacy benefits will not change. Medication, enteral nutrition products, and disposable outpatient medical supplies such as those to manage diabetes will still be available with prescription from your child’s health care team. You should continue to use the same pharmacy.

Your health care team and pharmacy have received information about these changes and can answer your specific questions about your prescriptions. If you are not able to reach your provider or resolve any issue at the pharmacy, you can call the Medi-Cal Rx Customer Service Center any time of the day, 7 days a week, 1-800-977-2273 to receive assistance.

Additional information can be found on the Medi-Cal Rx website and in the Medi-Cal Rx Members – Frequently Asked Questions (FAQs).
 

L.A. Care uses a list of covered drugs called a formulary. Drugs on the list have been chosen for their safety and effectiveness. Your doctor should order drugs from this approved list.

Each plan has its own formulary. You can check if your medication is covered by browsing the formulary document for your health plan listed here. L.A. Care can also provide a copy of the formulary in your preferred language, large print, audio, or alternate format.

L.A. Care formularies are continually updated to provide safe, appropriate, and cost-effective drug therapies. These changes are listed in the documents below.

May 2025 Formulary Updates

April 2025 Formulary Updates

March 2025 Formulary Updates

February 2025 Formulary Updates

January 2025 Formulary Updates

Formulary Updates January - December 2024

Other Formulary Resources

PASC-SEIU Plan Formulary
L.A. Care Covered Direct Formulary
L.A. Care Covered Formulary
Medi-Cal Formulary
Medi-Cal Dual Formulary
L.A. Care Medicare Plus Formulary

Cost Share

Member cost share varies by plan. Please refer to your member handbook for specific cost share information.

Restrictions to coverage apply to certain prescription drugs. The Pharmacy and Therapeutics Committee develops restrictions to help our members use drugs in the most safe and effective ways. Some restrictions impact overall drug cost, which keeps our members' drug coverage more affordable. Other restrictions are designed to promote safe use of particular agents, such as opioids.

Prior Authorizations and Coverage Exceptions

One type of restriction is called a Prior Authorization (PA). Certain formulary medications require a Prior Authorization (PA) request to be submitted by the prescribing practitioner for our L.A. Care members. Prior Authorizations are reviewed based on the individual member's need. Medications that are non-formulary require a drug exception request, similar to a PA, to be submitted by the prescribing practitioner.

Policies regarding coverage exceptions vary by plan. Please refer to your member handbook for specific coverage exception information.

Step Therapy

Medications that have a step therapy requirement will require you to try medications in a certain order. If your practitioner feels that you need to use a Step Therapy drug without first trying a first step drug, he or she can submit a Prior Authorization Form with documentation of the medical need.

Quantity Limits

Medications that have a designated quantity limit, require that only the specified maximum amount of medication be filled during a certain period of time. If your practitioner feels that your medical condition requires a quantity of medication exceeding the specified limit, he or she can submit a Prior Authorization Form, along with documentation of medical need.

L.A. Care is encouraging members to use the free mail order service to fill prescriptions. The preferred mail order pharmacy for L.A. Care Medicare Plus members is Quality Drug Clinical Care (Quality Drug).

The mail order pharmacy for L.A. Care Covered, L.A. Care Covered Direct, and Homecare Workers Health Care plan members is Postal Prescription Services (PPSRX). Medi-Cal members can search for mail order pharmacies on the Medi-Cal Rx website by filtering for “mail order”.

Please look at the mail order FAQ for your specific plan:

• L.A. Care Covered and L.A. Care Covered Direct Member FAQs
• L.A. Care Medicare Plus Member FAQs
• PASC-SEIU Plan Member FAQs

L.A. Care Medicare Plus

The preferred mail order pharmacy for L.A. Care Medicare Plus members is Quality Drug Clinical Care (Quality Drug). To sign up or learn more, call L.A. Care member services at:

Medicare Plus (HMO D-SNP): 1-833-522-3767 (TTY 711)

If the medication(s) has no refill(s) remaining, prescribers will need to provide a new prescription. If you prefer to mail in your prescription request to Quality Drug, you can print out the form below.

Quality Drug Form
Quality Drug Form (Spanish)

L.A. Care Covered/Direct & Homecare Workers Health Care Plan

L.A. Care is providing members with mail order services through Postal Prescription Services (PPSRX). To sign up or learn more, call Postal Prescription Services at 1-800-552-6694 or log in to your Postal Prescription Services account to manage prescriptions, order refills, and review your prescription status here.

If the medication(s) has no refill(s) remaining, please call Postal Prescription Services at 1-800-552-6694 or request a refill online. If you prefer to mail in your prescription request to Postal Prescription Services, you can print out the form below.

Postal Prescription Services Form
Postal Prescription Services Form (Spanish)

Some L.A. Care members may be chosen to enroll in the Pharmacy Home Program. The Pharmacy Home Program will help members handle their controlled medications safely.

You may be chosen to enroll in this program if:

• You received prescriptions for controlled medications from three (3) or more providers.
• You filled prescriptions for controlled medications at three (3) or more pharmacies within the past 90-day period.

A Pharmacy Home is a pharmacy that works with L.A. Care where you will get all your prescriptions for controlled medications filled. If you are chosen to enroll in the program, L.A. Care will give you a written notice. You are able to choose one pharmacy that works with L.A. Care as your Pharmacy Home. If you do not choose a Pharmacy Home, L.A. Care will choose a pharmacy closest to you. In an emergency, you may get your prescriptions filled at another pharmacy. L.A. Care will let your doctor know when you are enrolled in the program.

L.A. Care will excuse you from the Pharmacy Home Program if:

• You are in hospice care, have sickle cell disease, or have cancer;
• Being in the Pharmacy Home Program causes you trouble in finding care or causes an unnecessary health risk;
• Other reasons will be considered on a case by case basis.
   

Safe Use of Opioids

Opioids are powerful medications often prescribed for pain relief, but they come with significant risks, including the potential for misuse, addiction, overdose, and death. While opioids can be effective in managing short-term pain, their long-term use may lead to tolerance, dependence, and other harmful side effects.

To manage pain safely, consider non-opioid options such as physical therapy, cognitive behavioral therapy, acupuncture, and mindfulness techniques. Non-opioid medications like acetaminophen, ibuprofen, and certain antidepressants or anticonvulsants may also provide effective relief for chronic pain conditions. Engaging in regular exercise, practicing relaxation methods, and using heat or cold therapy can complement these treatments, offering a holistic approach to pain management. Always discuss your pain management plan with a healthcare provider to find the most appropriate, safe, and effective treatment for your needs.

Opioid-Related Overdose & Naloxone

Opioid-related overdoses are occurring at high rates in the United States. In an effort to use opioid medications safely, naloxone should be considered.

Naloxone is a life-saving medication that is designed to quickly reverse an opioid overdose. It works by blocking the effects of opioids on the brain and is safe to use. This medication can be given by intranasal spray (into the nose), intramuscular (into the muscle), subcutaneous (under the skin), or intravenous (into a vein) injection. Access to naloxone can be a critical tool in combating the opioid crisis, and our members are encouraged to discuss its availability and use with their healthcare provider.