The medical drug benefit covers drugs that your doctor carries within their office. Your doctor will have purchased these drugs and the term for it is “Buy and Bill.” Drugs on the medical benefit may have limits or criteria that restrict its use to certain diseases, quantities, or drugs that have been tried and failed. The types of drug limits and access to a list of drugs on the medical benefit with any drug limits can be found on this page. When a drug is approved for use through the medical drug benefit, your doctor can bill the drug to HPSJ, along with any costs related to giving you the drug in office. There is no cost sharing with covered medical drugs. If a medical drug benefit request is not approved, you or your doctor may always request for an appeal here: Grievances & Appeals – Health Plan of San Joaquin (hpsj.com) (https://www.hpsj.com/grievances-appeals/).
However, there are certain drugs that Medi-Cal Rx covers on the pharmacy benefit but they still require your doctor to give them to you at the office. The list of drugs to where this applies can be found here: Medi-Cal Rx Pharmacy Reimbursable Physician Administered Drugs.
If a drug is on this list, the drug must be sent to a pharmacy (e.g. Accredo, CVS, Walgreens) to dispense the drug. Once you obtain the drug or the drug is sent directly to your doctor’s office, your doctor will be able to give you the drug dose in the office. For any other drugs that are dispensed at a pharmacy (e.g. Walgreens, CVS, Accredo), details on covered drugs through the pharmacy drug benefit can be found here: https://www.hpsj.com/benefits-pharmacy/.
Drug Limits (click each limit to learn more):
