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Pharmacist scanning a prescription container

L.A. Care's Formulary & Pharmacy Services

Understanding your pharmacy benefits.

Pharmacy Services

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.

 

Plan Partner Drug Coverage

If you receive health coverage through an L.A. Care Plan Partner – Anthem Blue Cross, Blue Shield of California Promise Health Plan, or Kaiser Permanente – then you must use pharmacies in that Plan Partner’s network. The list of covered drugs may also be different for each Plan Partner. Find a pharmacy and a list of covered drugs by calling your health plan provider.
 

Restrictions to Coverage

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. 
 

Formulary Updates – New drug additions and deletions

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

December 2019 Formulary Updates

November 2019 Formulary Updates

October 2019 Formulary Updates

September 2019 Formulary Updates

August 2019 Formulary Updates

July 2019 Formulary Updates

June 2019 Formulary Updates

May 2019 Formulary Updates

April 2019 Formulary Updates

March 2019 Formulary Updates

February 2019 Formulary Updates

January - December 2018 Formulary Updates

 
Prior Authorizations

Prior Authorizations and Coverage Exceptions

One type of restriction is called a Prior Authorization (PA). Certain formulary medications require a written 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 written 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.

If you need assistance with the Prior Authorization Request process, please contact L.A. Care Member Services, 1-888-839-9909 (TTY/TDD) 711.

 
Cost Share

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

 
An online option to order prescriptions

InternetAn Important Pharmacy Change for Members

L.A. Care is providing members with mail order services through our new contracted mail-order pharmacy, Kroger. 

Members can get a 90-day supply of maintenance medications through the mail-order pharmacy service or at a participating retail pharmacy location. Maintenance medications are drugs that may need to be taken for a long-term health condition, such as high blood pressure or diabetes. To set up a mail-order account or to order refill(s) for an unexpired prescription, access Kroger Mail Order Pharmacy. 

If the medication(s) has no refill(s) remaining, prescribers will need to provide a new prescription. This is a free service to members.

Kroger Mail Order Pharmacy Form
Kroger Mail Order Pharmacy Form (Spanish)
 

 
Member Services

Call 1-888-839-9909 for questions about your pharmacy benefits.

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Need to See if Your Drug is Covered?

You can now use our online Formulary Search to find out if a medication is covered under an L.A. Care health plan. 

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We're highlighting three key vaccines that can help you stay healthy, which you can get at your local pharmacy or doctor's office.

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Drug Recalls and Withdrawals

Manufacturer and FDA recalls and withdrawals.

 
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Links to Visit

Cal MediConnect Formulary
Kroger Mail Order Pharmacy

Resources

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