California’s protection & advocacy system

For legal assistance call 800-776-5746. For all other purposes call 916-504-5800 in Northern CA

or 213-213-8000 in Southern CA. TTY 800-719-5798.

 

Pharmacy Benefit Principles

Publication #1026 - Adopted 3/11/2005; Amended 06/21/2014
Individuals with disabilities should have access to affordable, necessary drugs of their choice on a voluntary basis. Disability Rights California opposes forced treatment of individuals with disabilities.


Necessary drugs of choice should be available.

      • Drug formularies should be as broad and comprehensive as possible so that doctors can prescribe the widest choice of drugs consistent with the individual’s preference. This recognizes the fact that not all drugs work for all people, and individuals may prefer to try different medications in an effort to find the one that works best for them.
      • There must be reasonable procedures for obtaining drugs that are not on a particular drug formulary. This might include a prior authorization or review process that is not overly burdensome on beneficiaries or providers.
      • Drug classifications that arbitrarily limit the number of classes of drugs, and the number of drugs per class should be avoided. For example, a formulary that establishes a classification for “antidepressants” but then further limits the available number of antidepressants to two would be unacceptable.
  1. Necessary drugs should be accessible.

      • Any State-sponsored drug program should ensure that a sufficient number of pharmacies participate so that drugs are available at pharmacies near the beneficiary’s residence.
      • Drug programs must ensure drugs are available by mail order and over the internet, and by way of home delivery.
      • Comprehensive access to prescription drugs should be available for dually eligible beneficiaries in the Medi-Cal and Medicare Part D programs to meet their medical needs. (Dually eligible beneficiaries are sometimes referred to as “dual eligible” or “duals.”)
      • There should be timely and meaningful eligibility dispute resolution for individuals, including dual eligibles, and continued coverage for medically necessary medication during the dispute resolution process.
      • The State should not leverage drug prices by imposing prior authorization under the Medi-Cal program on nonparticipating pharmacies.
      • Drugs should be available regardless of medical condition. This includes drugs for HIV/AIDS, psychiatric conditions, and severe pain.
      • To the extent permitted under federal law, the State should provide the same drug benefit to individuals dually eligible for Medi-Cal and Medicare as is available to individuals who are beneficiaries of Medi-Cal only.
  2. Necessary drugs should be affordable.

      • The State should participate in purchasing arrangements that enable it to obtain drugs at the lowest possible cost consistent with availability, access, and non-discrimination.
      • The State should ensure that individuals who need maintenance drugs, a number of drugs, or drugs for chronic conditions are able to obtain a reasonable supply and without undue cost.
      • The State should ensure that insurance premiums, deductibles, coinsurance or co-payments are not unduly burdensome so that beneficiaries can afford the drugs they need.