Formulary & Prescription
Information provided for CommuniCare Advantage (HMO D-SNP), a Medicare Medi-Cal Plan, is for the current benefit year. It is intended to be a summary of the plan. If you need a complete explanation of benefits, services and costs associated with this plan please refer to your Member Handbook.
Part D Program
In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies, these are pharmacies that contract with CommuniCare Advantage to provide your covered prescription drugs. There are some retail pharmacies in CommuniCare Advantage where you can obtain an extended supply of all medications.
To locate a retail pharmacy in CommuniCare Advantage network, please call Member Services or review the pharmacy listing.
CommuniCare Advantage has contracts with over 400 pharmacies that equal or exceed Medicare requirements for pharmacy access in the Plan's approved service area.
Filling prescriptions outside the network
In most cases CommuniCare Advantage only covers drugs filled at an out-of-network pharmacy when a network pharmacy is not available or in case of an emergency.
If you fill your prescription at an out-of-network pharmacy, you may be responsible for paying the full cost of the prescription. You may request CommuniCare Advantage to reimburse you for your share of the cost by submitting a claim form to the following address:
CommuniCare Advantage
Attention: Pharmacy & Formulary
2420 Fenton Street, Suite 100
Chula Vista, CA 91914
Mail Order Pharmacy Service
You may obtain maintenance medications through CommuniCare Advantage mail-order-pharmacy service. These are prescription drugs that you take on a regular basis for a chronic or long-term medical condition. Please note that these are the only drugs available through our mail-order service.
When you order prescription drugs through CommuniCare Advantage mail-order-pharmacy service, you must order at least a 31-day supply, and no more than a 93-day supply of the drug. Generally, it takes the mail-order pharmacy 10 days to process your order and ship it to you.
Low Income Subsidy Information
Members who qualify for CommuniCare Advantage have Medicare and Full-Scope Medi-Cal. By qualifying for Medi-Cal, you may also qualify for "Extra Help" with your Prescription Drug Coverage through Medicare Part D. This "Extra Help" is also called the Low Income Subsidy. Qualifying for this subsidy means you have no Part D premium under CommuniCare Advantage.
Typically, you would pay $0 - $11.20 co-pays for prescription drugs based on the level of Extra Help you receive. This information is still important to you if you decide to leave CommuniCare Advantage and go to another plan as co-pays may still apply. Please contact the plan for more details. Limitations, copays and restrictions may apply. For more information, call CommuniCare Advantage Member Services or read the CommuniCare Advantage Member Handbook. Benefits and/or copays may change on January 1 of each year.
Best Available Evidence
To access the CMS “Best Available Evidence Policy”, please click on the following link. You will be directed to the CMS Website.
2025 List of Covered Drugs (formulary)
CommuniCare Advantage will cover the drugs listed in our formulary as long as the drug meets the following criteria:
It is Medically necessary,
it is filled at a network pharmacy, or
filled through our network mail-order-pharmacy service, and
all coverage rules are followed.
The list of covered drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.
What drugs are on the 2024 List of Covered Drugs (Formulary)?
If you need a copy of the drug formulary, or for the most recent list of changes, please contact the Member Services Department at 1-888-244-4430 (TTY 1-855-266-4584). CommuniCare Advantage representatives are available 24 hours a day, 7 days a week, including holidays. To find out if your drug is on the formulary, please click on the 2024 List of Covered Drugs link to view the additional information regarding CommuniCare Advantage Formulary. The first part of this formulary booklet tells you how to find a drug on our most recent formulary list.
Click on the following link to access the most recent Formulary/Medication Listing.
- List of Covered Drugs (Formulary) (English)
- List of Covered Drugs (Formulary) (Spanish)
- List of Covered Drugs (Formulary) (Arabic)
- List of Covered Drugs (Formulary) (Vietnamese)
- List of Covered Drugs (Formulary) (Tagalog)
- List of Covered Drugs (Formulary) (Chinese)
- List of Covered Drugs (Formulary) (Farsi)
The prescription drugs included on this List of Covered Drugs are covered by CommuniCare Advantage. Other drugs, such as some over-the-counter (OTC) medications and certain vitamins, may be covered by Medi-Cal Rx. Please visit the Medi-Cal Rx website (www.medi-calrx.dhcs.ca.gov) for more information. You can also call the Medi-Cal Rx Customer Service Center at 800-977-2273. Please bring your Medi-Cal Beneficiary Identification Card (BIC) when getting prescriptions through Medi-Cal Rx.
Important Message About What You Pay for Vaccines – Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.
Over-The-Counter Benefits Catalog
CommuniCare Advantage members have a new OTC benefit for 2024. You will get $180 every quarter (three months), including tax, to spend on OTC items found in your OTC Catalog. Any unused amount will not carry over to the next quarter. Some limitations may apply. Please refer to the OTC catalog for more information or call the Member Services Department at 1-888-244-4430 (TTY 1-855-266-4584).
Over-the-Counter Benefit Catalog
Utilization Management (UM) & Quality Assurance UM
There are certain prescription drugs that CommuniCare Advantage may have additional requirements for coverage or limits. These requirements and limits ensure that CommuniCare Advantage members use these drugs in the most effective way. These requirements and limits were developed for CommuniCare Advantage by a team of doctors and/or pharmacists. These requirements were developed to assist us to provide quality coverage to our members.
The requirements for coverage or limits on certain drugs are listed as follows:
Generic Substitution: When there is a generic version of a brand-name drug available, CommuniCare Advantage network pharmacies will automatically give you the generic version, unless your doctor has requested the brand name drug and we have approved this request. You also have the option to request an exception (coverage determination).
Prior Authorization: CommuniCare Advantage you to obtain prior authorization for certain drugs. Authorized providers will need to obtain approval from CommuniCare Advantage before filling your prescription. Your prescription drug may not be covered if prior approval is not obtained from the plan. Please click on the following link to access CommuniCare Advantage Part D Prior Authorization Criteria:
Step Therapy: In some cases, CommuniCare Advantage requires you to first try one drug 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, CommuniCare Advantage may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.
Quantity Limits: CommuniCare Advantage limits the amount of drug that is covered per prescription, or within a specific time frame. Quantity limits are noted within the formulary.
Please call Member Services if you need to find out if the drug you take is subject to these additional requirements or limits. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren't able to meet the additional restriction or limit for medical necessity reasons, you, your physician, or other prescriber may request an exception (coverage determination). See your Member Handbook for more information about how to request an exception.
Quality Assurance
CommuniCare Advantage conducts drug utilization reviews for all of our members to determine you are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. These are conducted each time you fill a prescription and on a regular basis by reviewing CommuniCare Advantage. During these reviews, CommuniCare Advantage looks for the following medication red flags or problems:
Possible medication errors.
Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition.
Drugs that are inappropriate because of your age or gender.
Possible harmful interactions between drugs you are taking.
Drug allergies.
Drug dosage errors.
If CommuniCare Advantage identifies a medication red flag or problem during our drug utilization review, we will work with your doctor, or other prescriber to correct it.
Medication Therapy Management (MTM) Program
CommuniCare Advantage offers a medication therapy management (MTM) program to help you and your doctor(s) make sure that your medications are working to improve your health. This program is not a benefit. It is a voluntary program and is available free of charge to eligible members.
MTM Program Eligibility
Members who have three or more of the following chronic diseases, who take at least eight (8) Part D medications, and whose total 2024 drug cost for the year is expected to exceed $5,330, will be eligible for our program.
Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Congestive Heart Failure (CHF)
Diabetes
Hypertension
Dyslipidemia
Osteoporosis
Members who are determined to be at risk under the Drug Management Program (DMP), which is related to opioid utilization, will also be eligible for the MTM Program.
MTM Program Enrollment
All eligible members will be automatically enrolled into the MTM program. Eligible members will receive a welcome letter in the mail giving them the opportunity to call and schedule a comprehensive medication review (CMR), or to contact Member Services for any additional questions about the program.
Eligible members may also be contacted by CommuniCare Advantage’s contracted MTM pharmacists to schedule a CMR.
Purpose and Benefits of the MTM Program
The goal of the program is to help you:
Get the most from your medications
Lower your risk for harmful drug reactions
Find lower-cost alternatives to your medications
Get answers to your questions about prescriptions and over-the-counter (OTC) medications
Services offered with the MTM Program:
Comprehensive Medication Review (CMR). This service is provided annually.
Targeted Medication Review (TMR). This service is provided quarterly.
What is a Comprehensive Medication Review (CMR)?
A CMR is an interactive, person-to-person consultation with a pharmacist to review prescription and OTC medications. The review takes about 30 minutes to complete. After the CMR, the pharmacist will provide a written summary of the discussion which includes a personalized medication action plan and a personal medication list.
A blank copy of the Personal Medication List can be requested by calling Member Services. You can also download a blank copy by clicking on the following link: Personal Medication List
What is a Targeted Medication Review (TMR)?
A TMR is performed quarterly by pharmacists to assess medication use, to monitor whether any unresolved issues need attention, and to determine if new drug therapy problems have come up. The findings from these quarterly reviews can help determine if a follow-up intervention is necessary for the member and/or their prescriber.
Both CMRs and TMRs can be done in person or over the phone.
If you have any questions about our MTM program, please contact Member Services at 1-888-244-4430, TTY/TDD: 1-855-266-4584, 24 hours a day, 7 days a week, for additional information.
Drug Transition Policy
As a new member to CommuniCare Advantage you may be taking drugs that are not covered by our plan or may have certain restrictions. These may require prior authorization or step therapy. Existing members may be impacted by changes in our formulary from one year to the next. Please review CommuniCare Advantage Drug Transition Policy, by clicking on the following link:
Drug Transition Policy
Formulary Changes
CommuniCare Advantage may make changes to our formulary during the year. Some of the changes may affect covered drugs and how much you will pay when filling your prescription. These changes include:
Removing or adding drugs from the formulary
Requiring prior authorizations, changes to quantity limits, and/or step-therapy restrictions on a specific drug
Moving a drug to a higher or lower cost-sharing tier
What if your drug isn't on the formulary?
If you cannot locate your prescription in CommuniCare Advantage formulary, please call Member Services to be sure it isn't covered. Once Member Services has confirmed that your drug is not covered, you have the following options:
You can request your doctor to change you to another drug that is covered in our formulary.
You can request CommuniCare Advantage to make an exception to cover your drug.
You may choose to pay out-of-pocket for the drug and request that CommuniCare Advantage reimburse you by requesting an exception. Please note that this doesn’t mean that CommuniCare Advantage will reimburse you if the exception request isn't approved. You may appeal the Plan’s denial, if the exception isn't granted.
Drug Coverage Determination
You, your representative acting on your behalf, your prescribing physician, or other prescriber can request a standard or fast organization/coverage determination. A written request may be made by printing one of the forms below:
CMS Part D Coverage Determination Request Form
MedImpact Part D Coverage Determination Form
The completed form should be faxed, mailed, or delivered in person to:
CommuniCare Advantage
Attention: Pharmacy & Formulary
2420 Fenton Street, Suite 100
Chula Vista, CA 91914
For a fast decision call our Member Services Department at 1-888-244-4430 (TTY 1-855-266-4584). CommuniCare Advantage representatives are available 24 hours a day, 7 days a week, including holidays.
CommuniCare Advantage will make timely decisions when you ask us to cover a Medicare Part D prescription drug. A decision about whether CommuniCare Advantage will cover a Part D prescription drug can be:
A "standard decision" that is made with the standard time frame (typically within 72 hours)
A "fast decision" that is made more quickly (typically within 24 hours)
You can ask for a fast decision only if you, your doctor, or other prescriber believe that waiting for a standard decision could harm your health or your ability to function.
Fast decisions apply only to requests for Part D drugs that you have not received yet. You cannot get a fast decision if you are requesting payment for a Part D drug that you have already received.
If we tell you about CommuniCare Advantage decision not to provide a "fast" review by phone, you can request an expedited grievance at that time if you disagree.
CommuniCare Advantage will send you a letter explaining our decision within three calendar days after we call you. The letter will also tell you how to file a "grievance" if you disagree with CommuniCare Advantage decision to deny your request for a "fast" review, and will explain that CommuniCare Advantage will automatically give you a fast decision if you get a doctor's, or other prescriber's explanation.
Please refer to the Member Handbook for more details about this process.
Appeals and Grievances
CommuniCare Advantage provides an appeals and grievance process for our members to ensure you get answers to any concerns or problems you may encounter. You may also reference the "Complaints and Appeals" Section of the Member Handbook for additional detail regarding Grievances and Appeals.
Appeals
As a member, you can file an appeal if CommuniCare Advantage made a decision to not pay for, not approve, or stop a service you think should be covered or provided to you. This could include denials for drugs or involve payment for services (billing issues or reimbursement) you received or believe you should receive under the CommuniCare Advantage pharmacy program. You, your prescribing physician or other prescriber acting on your behalf and upon providing notice to you, or your appointed representative must file a written request for appeal within sixty (60) calendar days from the date of the notice of the coverage determination (i.e., the date printed or written on the notice).
You must send your appeal in writing to:
CommuniCare Advantage
Attention: Appeals Supervisor
2420 Fenton Street, Suite 100
Chula Vista, CA 91914
Or
fax to (619) 476-3834
CommuniCare Advantage will review your appeal and respond to you in writing advising you of our decision within seven (7) days of receiving your appeal request. If you
think your health could be seriously harmed by waiting for a decision about the drug, you, your prescribing physician or other prescriber can request a faster decision which is issued within 72 hours of receiving your appeal.
In both cases, you will receive a written notice of the outcome of your appeal, which will include any additional appeal rights which include an independent review entity; hearings before an Administrative Law Judge, review by the Medicare Appeals Council, and Judicial Review.
Grievances
A grievance is a type of complaint you make if you are dissatisfied with CommuniCare Advantage or our contracted providers for reasons other than a coverage decision. Grievances do not involve problems related to approving or paying for Part D drugs. You or your appointed representative may file a grievance about a Part D drug within 60 days of the event or incident. You may file a grievance by contacting the CommuniCare Advantage Member Services Department toll free at 1-888-244-4430 (TTY 1-855-266-4584). CommuniCare Advantage representatives are available 24 hours a day, 7 days a week, including holidays. You may opt to submit your Grievance in a letter and send it directly to CommuniCare Advantage at the following address:
CommuniCare Advantage
Attention: Grievance and Appeals Supervisor
2420 Fenton Street, Suite 100
Chula Vista, CA 91914
Or fax to (619) 476-3834
You will receive a written letter telling you that CommuniCare Advantage received your grievance, and the estimated time for a written response. A written resolution letter will be mailed to you within thirty (30) days of CommuniCare Advantage receiving your grievance.
For questions about the status of your grievance, call Member Services Department at 1-888-244-4430 (TTY 1-855-266-4584). CommuniCare Advantage representatives are available 24 hours a day, 7 days a week, including holidays.
For additional information regarding CommuniCare Advantage grievance process, please see the Member Handbook.
There are two kinds of grievances that you can request:
Expedited (Fast) Grievance (24 hour): You, any doctor, or your appointed representative can ask for a fast grievance if you disagree with CommuniCare Advantage decision not to give you a fast decision on a medical care issue, or if you disagree with our decision to take a time extension on an initial decision or appeal. CommuniCare Advantage will respond to this type of grievance by telephone, within 24 hours from the time that we received your complaint and within three calendar days, you will receive a written letter.
Standard Grievance (30 days) is any other type of complaint. CommuniCare Advantage must respond to you promptly as your medical condition requires, but no later than 30 calendar days after receiving your complaint.
If you are concerned about the quality of care you received, you can also send your complaint to CommuniCare Advantage , the Quality Improvement Organization (QIO), an independent review organization, or both. The QIO is called Livanta. Complaints to Livanta must be in writing to the following address:
Livanta
BFCC-QIO Program
9090 Junction Drive, Suite 10
Annapolis Junction, MD 207011
TTY: 1-855-887-6668
Livanta California Medicare Beneficiary Complaints Helpline: 1-877-588-1123, or TTY 1-855-887-6668.
Appointment of Representative
You have the option to appoint a representative to act on your behalf and request a coverage determination, formulary exception, grievance and/or an appeal.
You can name a relative, friend, advocate, doctor, or someone else to act for you. You have the option to appoint a representative to act on your behalf and request a coverage determination, formulary exception, grievance and or an appeal. When completed, this form allows this person legal permission to act as your authorized representative. Please click on the following link to access CMS' Appointment of Representative Form (Form CMS -1696):
The completed form should be faxed, mailed, or delivered in person to:
CommuniCare Advantage
Attention: Pharmacy & Formulary
2420 Fenton Street, Suite 100
Chula Vista, CA 91914
Or fax to (619) 476-3834
Electronic Complaint Form
To download a blank copy of the Electronic Complaint Form, click https://www.medicare.gov/MedicareComplaintForm/home.aspx
You may also access additional information on Medicare’s website at https://www.medicare.gov/
Disclaimers
CommuniCare Advantage (HMO D-SNP) is an HMO D-SNP health plan with a Medicare contract and a contract with the Medi-Cal program. Enrollment in CommuniCare Advantage depends on contract renewal.
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Last Website Update 10/1/2024
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