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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

*First Name:

*Last Name:

*Date of Birth:

*Member ID:

*Spoken Language:

*Phone:

*Email:

Check this box if you do not have a current address

No Current Address

*Address1:

Address2:

*City:

*State:

*Zip:

*Is this a new phone number/address?

Yes

*Do we have your consent to forward new phone number and/or address to Social Services Administration?

Yes

*Does this consent apply to your whole family?

Yes

Requestor Information

*Relationship to Member:

*Requestor First Name:

*Requestor Last Name:

Received Permission from Member/Authorized representative?

Yes

*Requestor Spoken Language:

*Requestor Phone:

*Requestor Email:

Additional Information

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

*Doctor Name:

*Doctor Phone:

*Pharmacy Name:

*Pharmacy Phone:

Other Health Information

*Is this a new medication for you?

Yes

*Do you have enough medication to last until the next business day?

Yes

*Do you have a prescription from your doctor?

Yes

*Do you have other health insurance coverage?

Yes

*Other Health Insurance Name:

*Other Health Insurance Phone:

*Other Health Insurance Cardholder Name:

*Other Health Insurance Cardholder Date Of Birth:

*Other Health Insurance ID:

*Other Health Insurance Copay:

*Do you give us permission to leave a detailed message regarding this request?

Yes

Drug Information

*Drug Requested:

*Drug Strength:

*Drug Quantity:

*Drug Diagnosis:

*Reason for Prior Authorization:

Click to add drug (Max 5)

Summary Of Request

Summary:

Contact Medi-Cal Customer Service
You can contact us online or by phone, 24 hours a day, 7 days a week.
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1-800-735-2929 TDD/TTY
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New Medi-Cal Members

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Come to a meeting to learn about your new benefits
Frequently asked questions
Get quick answers to common questions about Medi-Cal

Pharmacy

About the Medi-Cal pharmacy program
Learn about your drug benefits
Request drug prior authorization
Online form for drugs not on the approved drug list

Forms and Documents

Common Medi-Cal forms
Authorizations, requests and more
Other important documents
Language assistance, Notice of Nondiscrimination and other helpful information.

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