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Drug Formulary and Pharmacy Benefits

California Kids Care Members may obtain specialty drugs from the Rady Children’s Hospital-San Diego retail and homecare pharmacies, and covered outpatient prescription drugs from covered pharmacies, located throughout San Diego County.

Prior Authorization

Some medications require prior authorization. In these situations the prescribing Provider must request a Prior Authorization and submit it with relevant supporting medical information. California Kids Care will evaluate the information submitted with the request and make a decision based on the established clinical criteria for that medication.

Brand Name Drugs

California Kids Care does not cover a brand-name drug when a generic drug is available, unless there is a medically indicated and properly documented reason why the brand-name drug should be used.

The Food and Drug Administration (FDA) applies rigorous standards for ensuring the identity, strength, quality, purity and potency of a medication before approving its use as a generic drug. Generics are required to have the same active ingredient, strength, dosage form and route of administration as their brand name equivalents. If a Member cannot use the generic version of a medication due to an adverse reaction, Providers are instructed to report the finding to the FDA using the MedWatch report form. Providers can then submit a copy of the completed MedWatch form and a Prior Authorization Request form to California Kids Care to request coverage for prescription of the brand name drug.

Specialty Drugs

Specialty drugs are drugs that may require specialized delivery and administration on an ongoing basis. They are typically for chronic conditions and involve complex care issues that need to be carefully and actively managed. If available through Rady Children’s Hospital-San Diego’s retail or home care pharmacy, such specialty drugs will be provided exclusively through Rady Children’s Hospital.

Pharmacy Benefit Resources

The following information is provided to assist Providers who prescribe outpatient prescription drugs for California Kids Care Members. Follow the links below for more information about the outpatient prescription drug benefits available through California Kids Care.

If you can’t find what you are looking for, please don’t hesitate to pick up the phone and call Member Services at 1-844-225-5430 (TTY 711), or send an email to CaliforniaKidsCare@rchsd.org.