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MediCal Explained

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What is CMSP?

The County MediCal Services Program (CMSP) provides health coverage for low-income, indigent adults in thirty-four, primarily rural, California counties. The eleven-member CMSP Governing Board provides policy direction for the program. As a part of this responsibility, the Governing Board sets program eligibility requirements, determines the scope of covered health care benefits, and sets the payment rates paid to health care providers delivering services to CMSP members.

The Governing Board contracts with Anthem Blue Cross Life & Health Insurance Company to administer CMSP. In its administration of the program, Anthem Blue Cross has contracted with a wide range of healthcare providers to form the Anthem Blue Cross/CMSP Provider Network. This Network provides non-emergency and emergency services to CMSP members.

Characteristics of CMSP program administration include:

  • Healthcare providers contract with Anthem Blue Cross to participate in the Anthem Blue Cross/CMSP Provider Network. Only providers participating in the Network may receive payment for non-emergency health care services provided to CMSP members.
  • CMSP provides payment for emergency health care services provided to CMSP members by Network providers and all other providers of emergency services in California and in the designated areas of the border states of Oregon, Nevada and Arizona.
  • CMSP provides NO coverage for any health care services provided outside of California and the designated areas of the border states of Oregon, Nevada and Arizona.
  • All treatment authorization requests for MediCal, dental and vision services are processed by Anthem Blue Cross or its dental and vision service subcontractors.
  • Anthem Blue Cross utilizes the Milliman Practice Guidelines, supplemented by Wellpoint Practice Guidelines, to review and consider Treatment Authorization Requests (TARs).
  • Payment for MediCal, dental and vision services is processed by Anthem Blue Cross and its dental and vision services subcontractors in accordance with current HIPAA standards. Both paper and electronic billings are processed.
  • MedImpact Health Systems Inc. (MedImpact) administers the CMSP prescription drug benefit, including the processing of prior authorization requests and claims payment. As approved by the CMSP Governing Board, the CMSP prescription drug benefit emphasizes the use of generic medications, where available and appropriate, and requires prior authorization and other utilization controls for selected medications based upon clinical efficacy, MediCal necessity and cost.
  • Claims for CMSP services are subject to treatment authorization requirements and utilization limits administered by Anthem Blue Cross on behalf of CMSP. In general, all MediCal service authorizations (TAR) are to be sent to Anthem Blue Cross. Dentists and Optometrists that are not part of an FQHC, RHC or tribal health clinic are required to submit authorizations to DentaQuest (previously Doral Dental) and Vision Service Plan (VSP), respectively. The CMSP/Anthem Blue Cross Provider Operations Manual (POM) is provided to all providers that contract to be a part of the CMSP/Anthem Blue Cross provider network. The POM describes how to obtain service authorizations and how to bill for services.
  • Eligibility for CMSP is determined by the county social services departments in the thirty-four participating CMSP counties in accordance with eligibility rules set by the Governing Board.

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What is a "TAR?"

A "TAR" is a "Treatment Authorization Request." Most "services," many medications and extension of prescription refills are subject to prior approval by CMSP. Your doctor will fill out and submit a TAR before providing services or renewing prescription refills. For prescriptions, your pharmacy will notify your MediCal parctitioner that a (new) TAR is required to renew refilled prescriptions, and will follow-up periodically to ensure that the TAR is submitted and approved. However, your physician is ultimately responsible for completing the TAR process.

Click here for additional information about the CMSP Prescription Drug Benefit.

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What is MediCal?

MediCal is California's Medicaid program. This is a public health insurance program which provides needed health care services for low-income individuals including families with children, seniors, persons with disabilities, foster care, pregnant women, and low income people with specific diseases such as tuberculosis, breast cancer or HIV/AIDS.  MediCal is financed equally by the State and federal government.

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How much should I be charged for my prescription medications?

The pharmacy is allowed to ask for a $1 copay, however, if you cannot afford it, you are not required to pay it in order to obtain your medication.

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Can I get my medication early?

Early refills are covered when there is an increase in dosage, if a beneficiary is going into or leaving a nursing home, or if the medications are lost or stolen.  The pharmacy may have to contact MediCal to get approval to dispense medication early.  Beneficiaries may receive up to a 100-day supply of many medications.  If you often run out of medication, contact your doctor and discuss adjusting your prescription to your current needs.

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Can I get my medications early if I am going on vacation?

MediCal does not allow for early refills of your medications unless medically necessary. You need to work with your pharmacy and physician to either increase the amount dispensed, when you know you will be going on vacation or to have medication delivered to you while you are on vacation.

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Why can I only get 30 pills if my prescription is for 60?

Some medications are restricted. If your prescription is for more than the restricted amount, the pharmacy can submit a Treatment Authorization Request or TAR to ask MediCal for permission to give you a higher amount.

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My Pharmacy told me my diabetic supplies are not covered.  Is that true?

Diabetic supplies such as test strips, lancets and syringes are covered and can only be obtained through a pharmacy.  Ask your pharmacy to call 1-800-541-5555 if they require additional assistance billing MediCal for your diabetic supplies.

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My pharmacy told me that MediCal does not cover my medication.  What should I do?

Some medications may require that the pharmacy submit a Treatment Authorization Request or TAR to ask MediCal for permission to fill your prescription.  It usually takes 24-48 hours for MediCal to process a TAR.

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Can I get the name brand medication when a generic is available?

Generic drugs are safe and effective, contain the same active ingredient and work the same way as the brand name.  MediCal can pay for a name brand drug if a generic is not available or if your doctor considers the name brand to be medically necessary. In cases where your doctor would like you to have the brand name when a generic is available, a Treatment Authorization Request may need to be completed by the pharmacy before you will be allowed to receive the brand name.

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Are over-the-counter (OTC) medications covered?

All OTC medications require a prescription.

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Can I request an early refill if my medication was lost or stolen?

MediCal will cover lost, stolen or damaged medications. The pharmacy may have to contact MediCal for authorization to dispense medication early.

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I am covered by Medicare and MediCal.  Why is MediCal not paying for my prescriptions?

Once a MediCal client is entitled to receive Medicare, Medicare Part D will cover most of your prescriptions. Medicaid will only pay for a few medications that are excluded by your Part D plan.  If you need assistance to find and enroll on a Part D plan, please call 1-800-Medicare or 1-800-633-4227.

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Does MediCal cover Viagra?

No. MediCal does not cover any drugs for sexual or erectile dysfunction.

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Does Medicaid cover smoking cessation products? (e.g. Zyban and nicotine patches)

MediCal pays for smoking cessation products.  Some products require pharmacy to contact MediCal for authorization. MediCal requires beneficiaries to enroll in a smoking cessation program.  Beneficiaries can call the Smokers’ Helpline at 1-800-NO BUTTS (1-800-662-8887) to enroll in a free program.

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Does MediCal have a formulary?

Yes, MediCal has a formulary that is call the "MediCal List of Contract Drugs" (CDL). Drugs on this list generally do not require prior authorization; drugs not on the list require prior authorization (see question #14).  The list can be found on the MediCal website under Providers and Partners/Pharmacy Benefits/Contract Drug List. Updates are made to the list on a monthly basis. Medications are listed by their generic name.

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What drugs require Prior Authorization (PA)?

All drugs that are not listed the CDL require a Treatment Authorization Request (TAR).  Also if a drug is being used beyond a restriction listed on the CDL or it is the 7th or more prescription in a month, a TAR is usually required.

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Can a "retroactive" TAR be obtained for a previously filled prescription?

Retroactive TAR requests can be submitted if they are requested within 180 days of the recipient’s eligibility award date. These requests can be approved back to the recipient’s eligibility effective date.

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Why are some cough and cold products covered and some non-covered?

Cough and cold products are an optional coverage class according to the federal law. MediCal covers only cough and cold products that have been approved by the FDA to be safe and effective.

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