What is a formulary substitution?

Drug Formularies and Therapeutic Interchange H-125.991 (f) Therapeutic substitution: the act of dispensing a therapeutic alternate for the drug product prescribed without prior authorization of the prescriber.

What is formulary excluded?

A formulary exclusion list includes the drugs that an insurer, health plan, or pharmacy benefits manager (PBM) does not cover. Proponents of drug formulary exclusion lists say they quell costs by having patients use lower cost drugs. Ideally, patients should be using drugs that are the best value for their cost.

What does removed from formulary mean?

If a drug is removed from your formulary, members who were already receiving the drug will continue to have the medication covered for as long as the treating physician continues to prescribe the drug, provided the drug is being prescribed appropriately and is considered safe and effective for treating the member’s …

Does Medi-Cal pay for prescription drugs?

Medi-Cal will cover most prescriptions. In order to be covered, first, the prescription has to allow you to stay healthy or treat a medical problem. There is a list of approved medicines that Medi-Cal will cover without further verification.

What does substitution allowed mean on a prescription?

4=Substitution Allowed-Generic Drug Not in Stock-This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic substitution is permitted and the brand product is dispensed since a currently marketed generic is not stocked in the pharmacy.

Do I have to pay Medi-Cal back?

The Medi-Cal program must seek repayment from the estates of certain deceased Medi-Cal members. Repayment only applies to benefits received by these members on or after their 55th birthday and who own assets at the time of death. If a deceased member owns nothing when they die, nothing will be owed.

What is the difference between generic substitution and therapeutic substitution?

All generic versions of a drug are considered by the licensing authority to be equivalent to each other and to the originator drug. Therapeutic substitution is the replacement of the originally-prescribed drug with an alternative molecule with assumed equivalent therapeutic effect.