Cal MediConnect Coverage Explanation

Provider Type

  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

Prescription medications are covered under Health Net's Cal MediConnect Part D plan. Pharmacy coverage is indicated on the member's identification card. All covered prescriptions are listed on Health Net's Cal MediConnect Formulary. Some medications may require prior authorization by Health Net's pharmacy benefit manager (PBM).

Coverage for Immunosuppressive Medications

Immunosuppressive medications for a Medicare-covered transplant are covered under Part B.

Coverage for Non-Prescription Medications

Select Centers for Medicare & Medicaid Services (CMS) Part D-excluded non-prescription (over-the-counter) medications are covered under Health Net's Cal MediConnect plan. Over-the-counter medications are only covered when appropriately dispensed on receipt of a legal prescription.

Exclusions and Limitations

The following exclusions and limitation apply to Health Net's Cal MediConnect Part D plan:

  • Medications dispensed by non-participating pharmacies may not be covered, except as specified in the member's Evidence of Coverage (EOC).
  • Only select over-the-counter medications are covered on the Cal MediConnect Formulary or through the prior authorization process when a prescriber writes a prescription for them.
  • Medications that can be purchased without a prescription over-the-counter are not covered even when a prescriber writes a prescription for it except when the medication is listed on Health Net's Cal MediConnect Formulary, or an exception for a non-formulary medication is granted.
  • Medications prescribed for cosmetic purposes - medications that are prescribed to enhance appearance, including those intended to treat wrinkles or hair loss, are not covered.
  • Medications prescribed for indications not approved by the Food and Drug Administration (FDA) are not covered unless:
    • The medication has been recognized for the treatment of that condition by one of the following:
      • The American Hospital Formulary Service (AHFS) Drug Information
      • DRUGDEX Information System
      • One of the following compendia, if recognized by CMS as part of an anticancer therapeutic regimen:
        • The Elsevier Gold Standard's Clinical Pharmacology Compendium
        • The National Comprehensive Cancer Network Drug and Biologics Compendium
        • The Thomson Micromedex DrugDex Compendium
      • Two articles from major peer-reviewed medical journals that present data supporting the proposed off-label use or uses as generally safe and effective unless there is clear and convincing contradictory evidence presented in a major peer-reviewed medical journal.
    • It is the responsibility of the participating prescriber to submit to Health Net documentation supporting compliance with these requirements.
  • Hypodermic syringes and needles are not covered except for insulin needles and syringes.
  • Lost, stolen or damaged medications are not covered. The member must pay the retail price to replace them.
  • Medications prescribed for sexual dysfunction, including medications that establish, maintain or enhance sexual function or satisfaction, are not covered.
  • Nutritional supplements and homeopathic medications or vitamins, except prenatal and children's vitamins with fluoride, are not covered.

Accessing Medi-Cal Covered Medications

Members enrolled in Health Net's Cal MediConnect plan can access medications in certain CMS-excluded medication categories that are covered by Medi-Cal through a Health Net network pharmacy. To obtain the highest level of benefits, members must ensure the medication is listed on the Health Net Cal MediConnect Formulary. Prior authorization is required for non-formulary medications. Members may obtain prescription medications from an out-of-network pharmacy under certain conditions.

Cal MediConnect Medi-Cal Medication Coverage

Coverage includes medications in the following categories when listed on the Health Net Cal MediConnect Formulary:

  • Anorexia, weight loss or weight gain
  • Certain vitamin and mineral products (excluding dietary supplementation)
  • Symptomatic relief of coughs and colds
  • Selected non-prescription medications (including nicotine products)

Covered products are comparable to the Medi-Cal Fee-for-Service (FFS) Contract Drug List. Non-prescription (over-the-counter) medications are only covered when the member presents a valid prescription at a Health Net network pharmacy.