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Medi-Cal Member Handbook / Benefit Year 2006-2007Non-Covered Services:What does Medi-Cal notcover?The following is a list of services not covered byL.A. Care/Community Health Plan or by theregular Medi-Cal program:• All services excluded from Medi-Cal understate and/or federal law• Routine circumcision, unless medically necessary• Cosmetic surgery (surgery performed to alteror reshape normal structures of the body inorder to improve your appearance)• Custodial care• Experimental and investigational services.This is talked about in “IMRs for Experimentaland Investigational Therapies (IMR-EIT)”under “Complaints: What should I do if I amunhappy?” in this handbook• Infertility• Immunizations (shots) for work or travel• Personal comfort items, (such as phones,television and guest tray) when in the hospital• Temporal Mandibular Joint (TMJ) diseaseunless medically necessary after examinationIf you have questions about what is covered ornot covered, please call Community HealthPlan.21Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273
Medi-Cal Member Handbook / Benefit Year 2006-2007Pharmacy Benefits:How do I get prescriptiondrugs?What is a pharmacy?A pharmacy is a place to get your prescriptionsfilled. Community Health Plan works withpharmacies in many neighborhoods. You mustget your prescribed medications (drugs) from apharmacy in Community Health Plan’s network.A “network” is all of the pharmacies that workwith Community Health Plan. A pharmacy list isin the provider directory with this handbook. Or,you can call Community Health Plan at 1-800-475-5550 for pharmacies in your neighborhood.How to get a prescription filled1. Choose a pharmacy that works withCommunity Health Plan.2. Bring your prescription to the pharmacy.3. Show the pharmacy your L.A.Care/Community Health Plan ID card.You should not be asked to pay for coveredprescription drugs. Call Community HealthPlan if a pharmacy asks you to pay.What is a formulary?Community Health Plan uses a list of approveddrugs called a “formulary.” A committee ofCommunity Health Plan physicians and pharmacistsreviews drugs to add or remove from theformulary every three months.• Approved by the Food and Drug Administration(FDA)• Generally accepted to be safe and effective• Cost effectiveYour doctor usually prescribes drugs from theformulary. Your doctor will only prescribe a drugbased on your health status. Just because a drug ison the formulary does not mean a doctor willprescribe it. You doctor may not believe you needit.You may call Community Health Plan to ask for acopy of the formulary. You may also callL.A. Care for a list that compares all health planpartner formularies.Drugs not on the formularySometimes, your doctor may need to prescribe adrug not on the formulary. Your doctor must callto get an okay from Community Health Plan.To decide if this drug will be covered,Community Health Plan may ask your PCPdoctor or the pharmacist (or both) to find outmore. Within 24 hours after getting this information,Community Health Plan will tell your PCPdoctor or the pharmacist if the drug will becovered. Your PCP doctor or the pharmacist willtell you.If the drug is approved, you can get the drug at apharmacy that works with Community HealthPlan. If the drug is not approved, you have theright to appeal the decision. An “appeal” is whenyou want a decision to be reviewed. This is talkedabout in “Complaints: What should I do if I amunhappy?” in this handbook.Drugs can be added to the formulary when theyare all of the following:22Community Health Plan Member Services Department toll-free 1-800-475-5550L.A. Care Health Plan Member Services Department toll-free 1-888-4LA-Care or 1-888-452-2273
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