Pharmacy Services

Pharmacy Services
What is a formulary?

Understanding your pharmacy benefits.

Pharmacy Services

L.A. Care uses a list of covered drugs called a formulary. Drugs on the list to your right 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 for your health plan. L.A. Care can 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, Care 1st 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. 

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

InternetL.A. Care provides members with mail order services through our contracted mail-order pharmacy.

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 WellDyneRx 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.


WellDyneRX Mail Order Form
WellDyneRX Mail Order Form (ES)