The Healthy Families Program is a state and federal-funded health coverage program for children with family incomes above the level eligible for no cost Medi-Cal and below 250% of the federal income guidelines ($36,576 for a family of three). Healthy Families: Pharmacy Click on the link below to obtain the Healthy Families Drug Formulary, which is listed by therapeutic class. Formulary (PDF) The medications listed on this formulary are subject to change pursuant to the formulary management activities of L.A. Care Health Plan (L.A. Care) and its Plan Partners, and approval by applicable regulatory agencies. The presence of a medication on this formulary does not guarantee that a member will be prescribed that drug by his or her primary care physician or contracting provider for a particular medical condition. If a generic medication is available, it may be dispensed in place of the brand name medication. Members should consult their Evidence of Coverage or contact the Plan Partner Provider Information Line for additional information. Brand name medications are the registered trademarks of their manufacturers.   The Healthy Families Pharmacy Reference Guide lists key phone numbers and the fee-for-service drug carve-out list. Download the Healthy Families Prior Authorization Form

Benefits The following chart is a summary of covered services under L.A. Care's Healthy Families Program. Plan Benefits L. A. Care Health Plan Covered Services Healthy Families Program Member Pays Health Facilities Inpatient Room and board, general nursing care, ancillary services including operating room, intensive care unit, prescribed drugs, laboratory, and radiology No co-payment Outpatient Same as above, if provided on an outpatient basis No co-payment Professional Services Inpatient Licensed hospital, skilled nursing facility, hospice, mental health facility No co-payment Outpatient Office or home visit $5/visit Outpatient Chemotherapy, dialysis, surgery, anesthesiology, or radiation No co-payment Other Services Preventive Care Immunizations, periodic health exams, well-child visits, STD tests, cytology exams No co-payment Hearing Aids/ Services Audiological evaluations, hearing aids, supplies, visits for fitting, counseling, adjustments, repairs No co-payment Eye Exams/ Supplies Refractions to determine the need for corrective lenses; dilated retinal eye exams; cataract spectacles and lenses No co-payment Diagnostic X-ray and Laboratory Services Therapeutic radiological services, ECG, EEG, mammography, other outpatient diagnostic laboratory and radiology tests No co-payment Prescription Drugs Outpatient Generic or brand name drugs (30-34 day supply); 90-100 day supply of maintenance drugs (oral and injectable); tobacco cessation drugs for one cycle per benefit year, $5/prescription Prescription Drugs Inpatient & Doctor's Office Inpatient drugs, drugs administered in a doctor's office, and FDA approved contraceptive drugs and devices No co-payment Orthotics and Prosthetics Orthotics and prosthetics as prescribed by L. A. Care Health Plan providers No co-payment Perinatal/ Maternity Care Prenatal care and postnatal care, inpatient and newborn nursery care No co-payment Well Baby Care Health examinations and other office visits for subscribers under 24 months of age. No co-payment Family Planning Counseling, surgical procedures for sterilization, contraceptives No co-payment Medical Transportation Ambulance transportation when medically necessary No co-payment Emergency Care 24-hour care for alleviation of sudden, serious and unexpected illness, injury or condition requiring immediate diagnosis in and out of the Plan $5/visit (waived if admitted to hospital within 12 hours) Mental Health Inpatient Inpatient treatment (limited to 30 days per benefit year), 2 days of residential treatment may be substituted for 1 day of inpatient care, 3 days of day care may be substituted for 1 day of inpatient care, or 4 outpatient visits for 1 day of inpatient care No co-payment Mental Health Outpatient Outpatient visits (up to 20 per benefit year), group therapy; 4 outpatient visits may be substituted for 1 day of inpatient care. $5/visit Blood and Blood Products Inpatient and outpatient processing, storage, and administration, and collection and storage of autologous blood, when medically necessary. No co-payment Alcohol and Drug Abuse Inpatient Hospitalization to remove toxic substances from the system. No co-payment Alcohol and Drug Abuse Outpatient Crisis intervention and treatment, 20 visits per benefit year. $5/visit Home Health Services (except for physical, occupational, or speech therapy in the home) No co-payment Skilled Nursing Facilities Medically necessary skilled care; room and board; x-ray, laboratory and other ancillary services; medical social services; drugs, medications and supplies up to 100 days per benefit year No co-payment Hospice Medically necessary skilled care; counseling; supplies; short term inpatient care for pain management; bereavement services; homemaker services; physical, speech and occupational therapies; medical social services; short-term inpatient and respite care No co-payment Transplants Medically necessary organ and bone marrow transplant; medical and hospital expenses of a donor or prospective donor; testing expenses and charges associated with procurement of donor organ No co-payment Therapies, Home & Outpatient Physical, occupational, speech therapy $5/visit Therapies, Inpatient Physical, occupational, speech therapy No co-payment Spectacles & Contact Lenses Following cataract removal surgery. No co-payment Health Education Effective health education services and materials No co-payment Durable Medical Equipment Equipment for home use as medically necessary. No co-payment   Copayments Copayments should be collected at the time of service for most covered benefits in the Healthy Families program, as described in the Evidence of Coverage. There are two reasons why copayments may not be required at the time of service: 1. When covered services are provided at an Indian Health Services Facility to a Native American (as required by Federal Law). 2. When the $250 copayment maximum per family has been reached during the benefit year. In this situation, the family should call L.A. Care's Member Services department. No additional copayments will be collected during the remainder of the benefit year. L.A. Care works with participating providers to provide extended payment plans for members utilizing a significant number of services for which copayments are charged. Annual Copayment Maximum In no event will a member and their family, as a whole, during any one benefit year, have to pay more than the maximum annual copayment amount of $250. Annual or Lifetime Benefit Maximum There is no annual or lifetime financial benefit maximum for coverage under the Healthy Families program. Member Liability Except for any applicable copayments, members are not financially responsible for covered services provided by their doctor or for authorized services provided by other participating providers. Participating providers have been notified by L.A. Care that they cannot seek payment for these services from the member or member's family. Covered services, which have not been authorized, will not be covered by L.A. Care and may be the financial responsibility of the member, unless such services are emergency services, as determined by L.A. Care. Health care services which are not covered are the financial responsibility of the member, even if such services are referred by the member's doctor. News/Updates Provider Bulletin Spring 2005 Provider Bulletin Spring 2004 Provider Bulletin Winter 2004 Provider Bulletin Summer/Fall 2003 Provider Bulletin Spring 2003 Healthy Families Open Enrollment Begins April 15 Barriers to Care - Public Charge Working With You To Build Enrollment Provider Performance Incentive Program Board Certified Physicians Sought