OneCare (HMO SNP)

Pharmacy Program

Your pharmacy and medication benefits

Medicare Part D coverage is a federal program that helps pay for prescription medication. A formulary is a list of drugs covered by OneCare (HMO SNP). Under OneCare, your pharmacy benefits are covered with small co-payments. After you pay your co-payment, we will pay for drugs listed in our formulary if:

  • The drug is medically necessary
  • The prescription is filled at a network pharmacy
  • Other plan rules are followed

Some medications require approval before you can receive them. This is called “prior authorization.” In some cases, you must first try certain drugs to treat your medical condition before we will cover another drug for that condition. This is called “step therapy.”

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2019 OneCare list of covered drugs (formulary) This includes criteria for prior authorization. It also has criteria for step therapy.

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Find a Pharmacy Use the search tool to find a network pharmacy near you.

Other Important Pharmacy Information

Prescription drug transition and exceptions

New members may be taking drugs not on our formulary or subject to certain restrictions. You should talk to your primary care provider (PCP) to decide if you can switch to an appropriate drug we cover or request an exception. Current members can ask for an exception if your PCP prescribes a drug not covered.

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Medicare prescription drug transition policy Download PDF Icon This is CalOptima’s transition process for enrollees. It tells you how to get a temporary supply of non-formulary Part D drugs during the transition period. It also lists formulary drugs that have prior authorization or other utilization management restrictions.

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Request prescription drug coverage determination Download PDF Icon Use this form to ask for prior authorization or an exception.

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Prescription drug payment request Download PDF Icon If you paid out-of-pocket, use this form to request payment.

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Medication therapy management This program gives you tools to get the most from your drugs. It can help you stay healthy.

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Low-Income Subsidy Policy Download PDF Icon View the monthly plan premium for people who get extra help from Medicare to help pay for prescription drugs.

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To file a complaint with Medicare, click on the following link to complete a complaint form on the Medicare website: Medicare Complaint Form.

H5433_WEB020_M Accepted 06/17/19

OneCare (HMO SNP) is a Medicare Advantage organization with a Medicare contract. Enrollment in OneCare depends on contract renewal. Eligible beneficiaries can enroll at any time. Eligible beneficiaries must have Part A and Part B to enroll in the plan. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. Co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. Other Pharmacies/Physicians/Providers are available in our network. Medicare beneficiaries may also enroll in OneCare (HMO SNP) through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. Medicare has neither reviewed nor endorsed this information. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. OneCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This information is available for free in other languages. Please call our customer service number at 1-877-412-2734, 24 hours a day, 7 days a week. TDD/TTY users should call 1-800-735-2929.

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