You can find a network (contracted) pharmacy near you by using our online pharmacy locator. Our network includes retail, mail-order and specialty pharmacies.
Native American members can get services through Indian Health Service, Tribal, and Urban Indian Health Program pharmacies, even if these services are not in our network (non-contracted).
If you need help finding a pharmacy, call CalOptima Health Covered Customer Service toll-free at 1-888-312-2221 (TTY 711), Monday‒Friday, from 8 a.m. to 6 p.m. We have staff who speak your language. Show your CalOptima Health Covered member ID card at the pharmacy when you fill your prescriptions.
The CalOptima Health Covered Drug Formulary is a list of the most appropriate, safe and effective prescription medicines we cover. The Pharmacy and Therapeutics (P&T) Committee develops the Formulary. This committee is a team of practicing doctors, pharmacists and/or mental health providers who prescribe medicines. They review drugs in all therapeutic categories and choose the most appropriate based on safety, cost and clinical effectiveness.
The Drug Formulary is updated and posted monthly on CalOptima Health Covered’s website. Certain covered drugs have restrictions such as Step Therapy, Quantity Limits, and or require a Prior Authorization. Drugs that are not on the Drug Formulary require your provider to get prior authorization before you fill a prescription. FDA-approved generic drugs will be used in most situations, even when a brand-name drug is available. If your drug is non-formulary or has a restriction, your doctor will need to submit a prior authorization request. The request can be approved if there is a documented medical need. To see a full list and explanation of the pharmaceutical management procedures and restrictions, click on the links below.
Print Formulary (List of Covered Drugs)
CalOptima Health will provide members, upon request, a copy of the most current list of prescription drugs on the CalOptima Health Covered Drug Formulary by major therapeutic category, and show if any drugs on the list are preferred over other listed drugs. To request the Drug Formulary, please call CalOptima Health Covered Customer Service toll-free at 1-888-312-2221 (TTY 711), Monday‒Friday, from 8 a.m. to 6 p.m.
The CalOptima Health Covered plan includes generic, brand-name, and specialty drugs. The amount of your copayment or coinsurance depends on the drug category and/or tier indicated on the Formulary (for example, tier 1, 2, 3 or 4) and your benefit plan (for example, Silver or Bronze).
Tier 1: Most generic drugs and low-cost, preferred brand drugs.
Tier 2: Non-preferred generic drugs, preferred brand drugs, or drugs recommended by the P&T Committee based on drug safety, effectiveness, and cost.
Tier 3: Non-preferred brand drugs; drugs recommended by the P&T Committee based on safety, effectiveness, and cost; or drugs that generally have a preferred and often less costly therapeutic alternative at a lower tier.
Tier 4: Drugs that are biologics; drugs that the FDA or drug manufacturer requires to be distributed by specialty pharmacies; drugs that require training or clinical monitoring for self-administration.
The mail-order service is optional and free. Mail-order service allows you to get up to a 90-day supply of your maintenance medicines. Maintenance medicines are drugs that may need to be taken for a long-term health condition, such as high blood pressure or diabetes. To set up a mail-order account or to order refill(s) for an unexpired prescription, call mail-order pharmacy SortPak at 1-877-570-7787 (TTY 711), visit SortPak’s website at www.sortpak.com or visit CalOptima Health’s website at www.caloptima.org.
If a medicine has no refills left, you’ll need a new prescription from your provider.
When you join CalOptima Health Covered, we will help you continue to receive your medicine(s) so you do not miss any doses. You may be able to get a temporary supply of your current medicines, even if they are not on our Drug Formulary or have restrictions. This temporary supply may be provided for up to 30 days, depending on your prescription. This gives you time to talk with your provider about switching to a covered medication or requesting an exception. You or your provider can contact us for help during this transition.
CalOptima Health Covered Customer Service toll-free at 1-888-312-2221 (TTY 711), Monday‒Friday, from 8 a.m. to 6 p.m. for help. We have staff who speak your language.
If your medicine is not on our Drug Formulary, you may still be able to get it covered. You, your provider, or your authorized representative can ask for an exception. This requires the provider to get prior authorization from CalOptima Health before you fill the prescription. CalOptima Health will reply within 24 hours for urgent requests or 72 hours for standard requests.
Prescription Drug Prior Authorization or Step Therapy Exception Request Form (61-211)
Some medicines may require prior authorization before they are covered. This means your provider must contact us to show that the medicine is medically necessary before you can get it. If a medicine is not on our Drug Formulary, has been removed from the Drug Formulary, or has limits, you or your provider may ask for an exception. This means asking CalOptima Health to cover your medicine because it is medically needed. You may ask for a fast decision if waiting could harm your health. CalOptima Health Covered Customer Service toll-free at 1-888-312-2221 (TTY 711), Monday‒Friday, from 8 a.m. to 6 p.m. for help. We have staff who speak your language.
Exceptions to criteria or requests for coverage of drugs not on the CalOptima Health Covered Drug Formulary may be submitted by prescribers on CoverMyMeds or CalOptima Health Covered’s pharmacy benefits at www.caloptima.org.
Prescription Drug Prior Authorization or Step Therapy Exception Request Form (61-211)
If we deny coverage for a medicine, you have the right to file an appeal. You, your provider, or your authorized representative can request to review our decision.
We will review your appeal and notify you of the outcome within the required time frames: 24 hours for urgent requests and 72 hours for standard requests.
If you’re not satisfied with the outcome of your appeal, you may have the right to request an independent review through the California Department of Managed Health Care.
You have many ways to file a grievance. You can do any of the following:
CalOptima Health Covered can help you fill out the grievance form over the phone or in person. If you need help in another language, call CalOptima Health Covered Customer Service toll-free at 1-888-312-2221 (TTY 711), Monday‒Friday, from 8 a.m. to 6 p.m. to ask for an interpreter. Members with hearing or speech loss can dial 711.
Filing a grievance does not affect your medical benefits. If you file a grievance related to medical service, you may be able to continue a medical service while the grievance is being resolved. To find out more about continuing a medical service, call CalOptima Health Covered Customer Service.
If you pay out of pocket for a covered medicine, you may be able to submit a claim to request reimbursement. We will review your request and reimburse you, if eligible, based on your plan benefits and cost-sharing.
Claims must include required documents such as receipts and prescription information, and must be submitted within the required time frames. Call CalOptima Health Covered Customer Service toll-free at 1-888-312-2221 (TTY 711), Monday–Friday, from 8 a.m. to 6 p.m. for help submitting a claim. We have staff who speak your language.
We regularly monitor safety alerts and recalls issued by regulatory agencies and manufacturers.
If a medicine is recalled or withdrawn from the market, we act quickly to protect our members. This includes notifying affected members and providers of the recall. If you are taking a recalled medicine, contact your pharmacist or provider for guidance. Do not stop taking your medicine unless your provider or pharmacist tells you to do so.
If you have questions about your pharmacy benefits, need help finding a pharmacy, or want help with prior authorization, exceptions or appeals, please call CalOptima Health Covered Customer Service toll-free at 1-888-312-2221 (TTY 711), Monday–Friday, from 8 a.m. to 6 p.m. We have staff who speak your language. We are here to help you get the medicines you need.