California PHP

Sometimes when you get prescription drugs, you may need to pay the full cost right away, like if you use an out-of-network pharmacy, don’t have your PHP (HMO SNP) member ID card when you fill your prescription, or want a drug that is not our formulary or has a requirement or restriction that you didn’t know about or didn’t think applied to you. You can ask us to reimburse (pay you back). It is your right to be reimbursed by our plan whenever you have paid for the cost of covered prescription drugs. Save your receipt and send us a copy when you ask us to pay you back for our share of the cost.

Please contact Member Services. You will need to mail or fax your receipt for the prescription drug you purchased to us along with an explanation why you had to pay for the drug on your own. Please be sure you include your name and member ID (found on your member ID card) when you mail or fax your receipt to us.

By asking for reimbursement for prescription drugs you paid for, you are asking for a coverage decision from us. To make this coverage decision, we will check to see if the prescription drug you paid for is on our formulary. We will also check to see if you followed all the rules for using your coverage for prescription drugs.

If the prescription drug you paid for is covered and you followed all the rules, we will send you payment within 30 calendar days after we receive your request.

If the prescription drug is not covered, or you did not follow all the rules, we will not send payment. Instead, we will send you a letter that says we will not pay for the drugs and reasons why.

If you do not agree with our decision, you can make an appeal. We must give you our answer within seven calendar days after we receive your appeal.

For more information about asking us to reimburse you for services you paid for or pay a provider bill you received, please see Chapter 7 and Chapter 9, Section 6 of the 2024 Evidence of Coverage, or contact Member Services. You may contact Member Services to check on the status of your request for reimbursement.

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