Pharmacy Information and Programs
Your Pharmacy Benefits
Below you’ll find important information about your pharmacy and drug coverage.
Explanation of Benefits
When you use your prescription drug benefits, we will send you an Explanation of Benefits (EOB) statement in the mail. This is for your Medicare prescription drug coverage (Part D). Your EOB shows:
- The prescriptions you filled
- What we paid
- What you and others have paid
- What counts towards your Out-of-Pocket Costs and your Total Drug Costs
Your EOB is not a bill.
If you paid a co-pay or coinsurance for your drug, the EOB should show the amount you paid.
You may not get an EOB every month
When we get a claim (bill) from your pharmacy, you’ll get an EOB the next month. For example, if we get a claim in March, you’ll get an EOB in April.
Take a minute to look over your EOB
Check your EOB to make sure everything is correct. If you have questions, find mistakes, or suspect fraud, we’re happy to help. Call us at the number below.
Search for Covered Drugs
CCA covers a wide range of both over-the-counter, brand-name and generic prescription drugs at no cost to you. Find out if a medication is covered under your plan and what to do when it’s not.
CCA Medicare Excel Plan
Real-time Benefit Tool
What’s my out-of-pocket expense? Click below to check up-to-date medication costs at your pharmacy of choice.
Drug Recalls
CCA is committed to protecting the health and safety of our members. We monitor alerts from the U.S. Food and Drug Administration (FDA) about drug recalls and withdrawals. We will notify you and your prescriber if we learn of potential problems with a medication.
A drug recall is when a medication or an over-the-counter product is removed from the market. A drug can be voluntarily recalled by the drug company and the FDA, or the FDA can require a recall. The FDA makes sure that recalls are handled correctly to safely stop the drug from being sold.
A drug may be recalled for many reasons, like safety concerns, mislabeling, or because it was poorly produced by the company.
Do not stop taking your medication until you speak to your doctor. In some cases, stopping a medication suddenly can cause a return of your symptoms that can be worse than before. In other cases, stopping a medication suddenly can be life-threatening. Follow these steps:
- Contact your doctor to discuss your options.
- Contact your pharmacy to discuss possible substitutes. For example, the pharmacist may be able to get the same medication from a different drug company. If not, they can contact your doctor to switch to another drug.
Visit the FDA website1 to learn more and to sign up to receive alerts on drug recalls.
What to do if you’re prescribed a drug that’s not on our formulary
If you’ve been prescribed a drug that’s not on the formulary (or “drug list”) you may still be able to get a temporary supply of the drug; request a similar drug that’s on the formulary; or ask the plan to grant an exception or otherwise remove restrictions. Refer to the transition process document based on the plan you’re enrolled in below.
Transition Process for CCA Medicare Excel (HMO), CA
Pharmacy Programs
CCA offers support with your medications through a range of free services and programs.
We have established measures and systems to conduct drug utilization reviews for all our members to make sure that they are getting safe and appropriate care. The programs include real-time and historic review of prescriptions claims to reduce medications errors and adverse drug interactions. These reviews are especially important for members who have more than one doctor who prescribes their medications, use more than one drug, or have more than one pharmacy.
CCA Health conducts drug utilization reviews when your pharmacy fills your prescription at the point-of-sale. The claim may be electronically reviewed for the following:
- Screen for duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
- Age-related contraindications
- Gender-related contraindications
- Drug–drug interactions
- Incorrect drug dosage
- Incorrect duration of therapy
- Clinical abuse or misuse
In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.
For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.
In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective. Whenever a safe, lower-cost drug will work just as well medically as a higher-cost drug, the plan’s rules are designed to encourage you and your provider to use that lower-cost option. We also need to comply with Medicare’s rules and regulations for drug coverage and cost sharing.
We also have special programs to help members use their drugs safely. We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.
We do a review each time you fill a prescription. Things we review include‚ but are not limited to: prior authorization‚ clinical edits‚ quantity limits, and step therapy.
Full List Review:
- Age limits: Some drugs may require a prior authorization if your age does not meet the manufacturer, FDA, or clinical recommendations.
- Quantity limits: For certain drugs, we limit the amount of the drug we will cover per prescription or for a defined period of time.
- Prior authorization: We require you to get prior authorization for certain drugs. (You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exceptions process.) This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.
- Step therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
- Generic substitution: When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug. If the brand-name drug is approved, you may be responsible for a higher copay and/or the difference in cost between the brand-name and generic medications.
You can have your prescriptions mailed to your home for free. The medications available for mail-order service are generally medications that you take on a regular basis for a chronic or long-term medical condition, such as those for high blood pressure, high cholesterol, or diabetes.
CCA partners with Birdi in California to provide this service. To set up medication delivery:
Register to get started. You can do this:
- Online at medimpact.com. You will need to provide information about your allergies, medications, contact information and shipping address. You can also request refills through your online account.
- By mailing this form to Birdi, PO Box 51580, Phoenix, AZ 85076-1580.
Your doctor will need to submit a 90-day prescription to Birdi to begin home delivery services. They can do this via:
- E-prescribing
- Faxing the prescription to (888) 783-1773.
Standard shipping is free. Your prescription drug copays remain the same. If you have a copay, you will be charged; if you do not have copays, you will not be charged.
Your prescriptions will be shipped within 5 business days of Birdi receiving your prescription or refill request.
CCA partners with MedImpact Direct Specialty in California to provide specialty medications. The dispensing pharmacy will call you to schedule medication delivery. Call 877-391-1103 with any questions about filling your specialty medications.
Medication Therapy Management (MTM) Program
Our Medication Therapy Management Program is focused on improving therapeutic outcomes for Medicare Part D members.
Better therapeutic outcomes for members with multiple conditions.
Our Medication Therapy Management (MTM) program is focused on improving therapeutic outcomes for Medicare Part D members. To qualify for the MTM program, a member must meet all the following criteria:
Members must have filled eight or more chronic Part D medications; and Members must have at least three of the following ten chronic conditions:
- Asthma
- Chronic Obstructive Pulmonary Disease (COPD)
- Congestive Heart Failure (CHF)
- Depression
- Diabetes
- High Blood Pressure
- High Cholesterol
- Osteoporosis
- Rheumatoid Arthritis
- HIV
In addition, members must be likely to incur 2024 annual costs of $5,330 for all covered chronic Part D medications.
If you meet all the criteria above, our MTM program will help you learn about how to manage the various medications you need to stay healthy free of charge.2
Our MTM program offers a wide range of services to help members with multiple conditions by:
- Ensuring they take their medications correctly
- Improving medication adherence
- Detecting potentially harmful medication uses or combinations of medications
- Educating members and health care providers
Comprehensive medication review (CMR)
You’ll have a one-on-one consultation with a clinician to ensure you’re taking your medications as prescribed by your health care provider(s).
The Centers for Medicare & Medicaid Services (CMS) requires all Part D sponsors to offer an interactive, person-to-person comprehensive medication review (CMR) to all MTM-eligible members as part of the MTM program.
If you meet the criteria outlined above, you’ll receive an MTM program enrollment mailer or phone call offering our CMR services. A CMR is a review of a member’s medications (including prescription, over the counter, herbal therapies, and dietary supplements) intended to assess your medication therapy and to optimize your outcomes.
Also, you’ll be included in quarterly targeted medication review (TMR) programs that assess medication profiles for duplicate therapy or drug-disease interaction in which your prescribers may receive a member-specific report.
The CMR includes three components:
1. Review of medications to assess medication use and identify medication-related problems. This may be conducted person-to-person or “behind the scenes” by a qualified provider and/or using computerized, clinical algorithms.
2. An interactive, person-to-person consultation performed by a qualified provider at least annually. This is typically conducted over the phone and will take about an hour to complete.
3. An individualized, written summary of the consultation for you which will include (but not be limited to) a medication list, reconciled medication list, and recommended to-do list for monitoring, education, or self-management. This will be delivered within two weeks of completing your CMR.
How to get started
You don’t need to do anything to access the program. A CCA representative will reach out to you if you meet the criteria to complete your CMR with you. To prepare for the CMR, you can download and complete the Personal Medication List below.
Medication List
1 When you click this link, you will leave the Commonwealth Care Alliance website.
2 This program is not a benefit; therefore, if you qualify for our program based on our criteria, we will automatically enroll you in the program and offer you program services over the phone or send you information by mail. The MTM program is free of charge to eligible members. Program participation is voluntary.