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 Connect. Under OneCare Connect, 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.”

2022 OneCare Connect list of covered drugs (formulary) This includes criteria for prior authorization. It also has criteria for step therapy.

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.

Medicare prescription drug transition policy 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.

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

Request for redetermination of Medicare prescription drug denial Use this form to ask for redetermination (appeal).

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

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

H8016_22WEB001_2022_A (Accepted 9/25/2021)

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