The Evidence of Coverage provides a description of health services provided through CalOptima Health. It details what your plan covers, how it works, and what you must pay.
The Summary of Benefits and Coverage provides an overview showing copays, deductibles, and other coverage information.
Bronze 60 HMO - Summary of Benefits and Coverage
Silver 70 HMO - Summary of Benefits and Coverage
Silver 73 HMO - Summary of Benefits and Coverage
Silver 87 HMO - Summary of Benefits and Coverage
Silver 94 HMO - Summary of Benefits and Coverage
Gold 80 HMO - Summary of Benefits and Coverage
An off-exchange plan meets the requirements of the Affordable Care Act and is sold directly by CalOptima Health, outside of the official Covered California marketplace.
Bronze 60 HMO - Off-Exchange Summary of Benefits and Coverage
Silver 70 HMO - Off-Exchange Summary of Benefits and Coverage
Gold 80 HMO - Off-Exchange Summary of Benefits and Coverage
Platinum 90 HMO - Off-Exchange Summary of Benefits and Coverage
Minimum Coverage HMO - Off-Exchange Summary of Benefits and Coverage
The Schedule of Benefits, part of the Evidence of Coverage, explains your payment responsibilities for covered services. To fully understand the details, including benefits, exclusions, and prior authorization, be sure to review both documents.
Bronze 60 HMO - Pediatric Dental Schedule of Benefits
Silver 70 HMO - Pediatric Dental Schedule of Benefits
Silver 73 HMO - Pediatric Dental Schedule of Benefits
Silver 87 HMO - Pediatric Dental Schedule of Benefits
Silver 94 HMO - Pediatric Dental Schedule of Benefits
Gold 80 HMO - Pediatric Dental Schedule of Benefits
Platinum 90 HMO - Pediatric Dental Schedule of Benefits
Minimum Coverage HMO - Pediatric Dental Schedule of Benefits
To find all providers who accept CalOptima Health Covered, look through our directory PDF or use our Find a Doctor tool.
View the Provider Directory PDF to see a list of providers in the CalOptima Health Covered network.
For the most up-to-date information about CalOptima Covered network providers, use the Find a Doctor tool to search by location, doctor type, language and more. You can also 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.
Prescription Drug Prior Authorization or Step Therapy Exception Request Form (61-211)
Commercial Prescription Drug Claim Form
Termination of Restriction Form
Statement Of Disagreement Request To Include Amendment Request And Denial With Future Disclosures
Request For Accounting on Disclosure Forms
Individual Request For Access to Protected Health Information Contained in Designated Request Set
Authorization To Disclose Protected Health Information to another person
Revocation of Authorization for Release Of Protected Health Information
Request for Restrictions Manner of Confidential Communication Form
Request For Restriction on Use and Disclosure of Protected health information
Search our network to find a trusted provider that meets your health care needs.
Need help enrolling or have questions? 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.
See the benefits and services our CalOptima Health Covered plan offers.
View our list of covered drugs (formulary) and find a participating pharmacy near you.