Formulary & Prescription Information

MedImpact Pharmacy

MedImpact is a pharmacy benefit manager who works with your health plan to get you the medication you need. MedImpact will work with your health plan and pharmacy to provide essential information about your medicine, including how to take it correctly, potential side effects, any lower-cost drug options, and more. Login or create an account to find lower cost options and manage your pharmacy benefits online or on the go by visiting https://www.medimpact.com/web/login

Part D Program

In most situations, prescriptions are covered only when filled at one of our contracted network pharmacies. These pharmacies partner with Community Advantage Plus to supply covered prescription drugs. A number of retail pharmacies in our network also allow you to pick up an extended supply of your medications. To locate a participating pharmacy, contact Member Services or consult our pharmacy directory.

Community Advantage Plus maintains agreements with more than 40 pharmacies—meeting or exceeding Medicare’s requirements for pharmacy access in the plan’s approved service area.

Filling prescriptions outside the network

Generally, prescriptions obtained outside of the network are not covered unless there is no network pharmacy available or you are experiencing an emergency. If you must use an out-of-network pharmacy, you may need to pay the full cost up front. You can then request reimbursement for your share of the cost by submitting a claim form to:

CHPIV Community Advantage Plus
Attention: Pharmacy & Formulary
P.O. Box 174, Imperial, CA 92251

Mail-Order Pharmacy Service

For maintenance medications—those taken regularly for chronic conditions—you may use Community Advantage Plus’s mail-order pharmacy. Only certain drugs are available through this service.

Mail orders must be placed for at least a 31-day supply, up to a maximum of 93 days. On average, processing and delivery take about 10 days.

Medicare’s “Extra Help” Program

Because you are eligible for Medi-Cal, you qualify for and are getting “Extra Help” from Medicare to pay for your prescription drug plan costs. You do not need to do anything to get this “Extra Help.”

Call Member Services at 1-888-484-1412 (TTY: 711). We are available 24 hours a day, 7 days a week, for any questions about this program.

Best Available Evidence

To access the CMS “Best Available Evidence Policy”, please click on the following link. You will be directed to the CMS Website.

Best Available Evidence (BAE)

2026 List of Covered Drugs (Formulary)

Community Advantage Plus will cover the drugs listed in our formulary as long as the drug meets the following criteria:

• It is medically necessary,
• It is filled at a network pharmacy, or
• Filled through our network mail-order-pharmacy service, and
• All the coverage rules are followed.

The list of covered drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

What drugs are on the 2026 List of Covered Drugs (Formulary)?

If you need a copy of the drug formulary, or for the most recent list of changes, please contact the Member Services Department at 1-888-484-1412 (TTY: 711).  Community Advantage Plus representatives are available 24 hours a day, 7 days a week, including holidays. 

To find out if your drug is on the formulary, please click on the 2026 List of Covered Drugs link to view the additional information regarding Community Advantage Plus Formulary. The first part of this formulary booklet tells you how to find a drug on our most recent formulary list.

List of Covered Drugs (Formulary) (English)
List of Covered Drugs (Formulary) (Spanish)

With Advantage Plus, the costs of your Medicare Part D medicines stay low.  Here is a link to our full list of medicines to meet your health care needs.  Your medications will have little to no copay from you.  Advantage Plus will cover the rest of the cost of your medications as long as the medicine is medically necessary and the prescription is filled at a network pharmacy. Advantage Plus offers home delivery via mail-order-pharmacy service. These are prescription drugs that you take on a regular basis for a chronic or long-term medical condition. Please note that these are the only drugs available through our mail-order service. When you order prescription drugs through Advantage Plus mail-order-pharmacy service, you must order at least a 31-day supply, and no more than a 93-day supply of the drug. Generally, it takes a mail-order pharmacy 10 days to process your order and ship it to you. Some of your medications may need to be approved before you get them.  This is called prior authorization.  You may also need “step therapy”, or try certain medications to treat your condition before we cover another medicine for it.

The prescription drugs included on this List of Covered Drugs are covered by Community Advantage Plus. Other drugs, such as some over-the-counter (OTC) medications and certain vitamins, may be covered by Medi-Cal Rx. Please visit the Medi-Cal Rx website (www.medi-calrx.dhcs.ca.gov) for more information. You can also call the Medi-Cal Rx Customer Service Center at 800-977-2273. Please bring your Medi-Cal Beneficiary Identification Card (BIC) when getting prescriptions through Medi-Cal Rx.

Important Message About What You Pay for Vaccines
Our plan covers most Part D vaccines at no cost to you. Call Member Services for more information.

Over-The-Counter Benefits Catalog

Community Advantage Plus members have a new OTC benefit for 2026. You will get $55 per month for qualified over the counter medications or use for fitness expenses (gym membership, etc.) Any unused amount will not carry over to the next month. Some limitations may apply. Please refer to the OTC catalog for more information or call the Member Services Department at 1-888-484-1412 (TTY: 711)

Medicare Prescription Payment Plan (M3P)

The Medicare Prescription Payment Plan is a free and voluntary service that allows Part D enrollees to spread their out-of-pocket prescription drug costs over monthly payments throughout the year instead of paying the full amount upfront at the pharmacy.

Starting January 1, 2026, members enrolled in the program will pay $0 at the pharmacy for covered Part D drugs. They will then receive a monthly bill from Community Health Plan of Imperial Valley for any cost-sharing, which will be divided into installments over the remaining months of the year. After enrolling in the program, members will not make payments to the pharmacy, they will instead make monthly payments to Community Health Plan of Imperial Valley.

Find out more about the Medicare Prescription Payment Plan Program and whether it may help you: 
Fact Sheet: What’s the Medicare Prescription Payment Plan (English PDF)
Fact Sheet: What’s the Medicare Prescription Payment Plan (Spanish PDF)

Request participation in the Medicare Prescription Payment Plan Program by filling out the online form: 

Medicare Prescription Payment Plan (M3P) Request Web Form

You can also download a copy of the Medicare Prescription Payment Plan Participation Request Form (PDF).
Medicare Prescription Payment Plan (M3P) request form – English PDF
Medicare Prescription Payment Plan (M3P) request form – Spanish PDF

Complete and mail or fax to:

CHPIV Community Advantage Plus
Attention: Member Services Department
P.O. Box 174 Imperial, CA 92251

FAX: 1-760-563-5187

Terms and conditions of participating in the Medicare Prescription Payment Plan Program:

Utilization Management (UM) & Quality Assurance UM

There are certain prescription drugs that Community Advantage Plus may have additional requirements for coverage or limits. These requirements and limits ensure that Community Advantage Plus members use these drugs in the most effective way. These requirements and limits were developed for Community Advantage Plus by a team of doctors and/or pharmacists to provide quality coverage to our members.

The requirements for coverage or limits on certain drugs are listed as follows:

If a drug is not covered in the way you would like it to be covered, you can ask us to make an exception. An exception is a type of coverage decision.

For us to consider your exception request, your doctor or other prescriber will need to explain the medical reasons why you need the exception approved. Here are some examples of exceptions that you or your doctor or other prescriber can ask us to make:

• Generic Substitution: When there is a generic version of a brand-name drug available, Community Advantage Plus network pharmacies will automatically give you the generic version, unless your doctor has requested the brand name drug and we have approved this request. You also have the option to request an exception (coverage determination).
• Prior Authorization: Community Advantage Plus allows you to obtain prior authorization for certain drugs. Authorized providers will need to obtain approval from Community Advantage Plus before filling your prescription. Your prescription drug may not be covered if prior approval is not obtained from the plan. 

Please click on the following link to access Community Advantage Plus Part D Prior Authorization Criteria:

Download Prior Authorization Criteria (English)

Step Therapy

In some cases, Community Advantage Plus requires you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Community Advantage Plus may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

Download Step Therapy Requirements (English)

Quantity Limits

Community Advantage Plus limits the amount of drug that is covered per prescription, or within a specific time frame. Quantity limits are noted within the formulary.

Please call Member Services if you need to find out if the drug you take is subject to these additional requirements or limits. If your drug is subject to one of these additional restrictions or limits and your physician determines that you aren’t able to meet the additional restriction or limit for medical necessity reasons, you, your physician, or other prescriber may request an exception (coverage determination). See your Member Handbook for more information about how to request an exception.

Quality Assurance

Community Advantage Plus conducts drug utilization reviews for all of our members to determine you are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes their medications. These are conducted each time you fill a prescription and on a regular basis by reviewing Community Advantage Plus. During these reviews, Community Advantage Plus looks for the following medication red flags or problems:

• Possible medication errors.
• Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition.
• Drugs that are inappropriate because of your age or gender.
• Possible harmful interactions between drugs you are taking.
• Drug allergies.
• Drug dosage errors.

If Community Advantage Plus identifies a medication red flag or problem during our drug utilization review, we will work with your doctor, or other prescriber to correct it.