Medi-Cal

Drug Prior Authorization Request

For drugs not on CalOptima’s approved drug list

To ask us for approval, fill out the form below or call our Customer Service department.

Your doctor must give you a prescription before you can fill out this form. It cannot be completed if you do not have a prescription from your doctor.

* = Required field

Member Information

 
 
 
 
 
 
 

 
 
 
 



Requestor Information

 
 
 

 
 
 

Additional Information  

Please list the name and phone number of your doctor OR pharmacy. You do not need to fill out both.
 
 

Other Health Information



 

 
 
 
 
 
 

Drug Information  

 
 
 
 
 

Summary Of Request

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New Medi-Cal Members
Pharmacy
Forms and Documents

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