Access our Pharmacy System
Members can register and login to our Pharmacy Benefit Manager (PBM) system by going to CarelonRx.com. This site allows members to search for pharmacy locations, price pharmacy claims, order mail order refills, determine generic availability for a drug, and lookup drug interactions and side effects.
Pharmacy Network Information
Optimum HealthCare, Inc. uses a network of pharmacies that is equal to or exceeds CMS requirements for pharmacy access in your area. Optimum HealthCare, Inc. currently has 4,992 in-network pharmacies. These pharmacies are contracted through our Pharmacy Benefit Manager (PBM), CarelonRx.
You can have your prescriptions shipped to your home through our network mail order delivery service. If you need your prescription immediately, have your doctor write 2 separate prescriptions. One prescription should be written for up to a 14 day supply. This prescription should be filled at your local retail pharmacy. The second prescription for the extended day’s supply should be mailed to the mail order pharmacy. If your prescription is already at the mail order pharmacy, you can ask them to send the prescriptions for next day delivery or 2 day delivery. There may be additional charges for this service.
For refills of your mail order prescriptions, you have the option to sign up for an automatic refill service. With this service, the processing of your next refill will begin automatically when our records show that you should be close to running out of your prescription. We will contact you prior to shipping each refill to make sure you need more medication. You can cancel scheduled refills if you have enough of your prescription or if it has changed. If you choose not to use the auto refill service, please contact us 10 days before the prescription you have on hand will run out to make sure your next order is shipped to you on time. To opt out of the automatic refill service, please contact your mail order service directly.
If you utilize CarelonRx, please call 1-833-203-1735, TTY/TDD users should call 711. Typically, you should expect to receive your prescriptions within 14 days from the time that the mail order pharmacy receives the order. If you do not receive your prescriptions within this time, please contact us at Optimum HealthCare, Inc., Member Services at 1-866-245-5360 or, TTY/TDD users should call 711. From October 1 to March 31 from 8:00 a.m. to 8:00 p.m. 7 days a week and April 1 to September 30 from 8:00 a.m. to 8:00 p.m. Monday through Friday.
We also have pharmacies that are in our network but are outside our service area. Please contact Optimum HealthCare, Inc. at 1-866-245-5360 for additional information. TTY users should call 711. From October 1 to March 31 from 8:00 a.m. to 8:00 p.m. 7 days a week and April 1 to September 30 from 8:00 a.m. to 8:00 p.m. Monday through Friday. Member Services also provides free language interpreter services for non-English speakers.
To search for a pharmacy, click on the "Pharmacy Network Listing" link below.
Formulary Information (List Of Covered Drugs)
A formulary is a list of drugs covered by your health plan.
To search for a drug, click on the link below. Once the page is opened, select the year, your county and plan. On the search page, type in your drug name or drug category in the search box. You can even download the Formulary in a PDF version.
The formulary list may change during the year. Updates, if any, will be posted monthly.
- What is a formulary?
- Can the formulary change?
- What about generic drugs?
- What if my drug isn't on the formulary?
Prior Authorization Criteria
Step Therapy Criteria
Drugs with Quantity Limits
Facts About Generic Drugs
What are generic drugs?
A generic drug is the same as a brand-name drug in:
- the way it works
- the way it is taken
- the way it should be used
Are generic drugs as safe as brand-name drugs?
Yes. The FDA says that all drugs must work well and be safe. Generic drugs use the same active ingredients as brand-name drugs and work the same way. Therefore, they have the same risks and benefits as the brand-name drugs.
Are generic drugs as strong as brand-name drugs?
Yes. FDA requires generic drugs must be as:
- high quality
- pure, and
- stable as brand-name drugs
Are brand-name drugs made in better factories than generic drugs?
No. All factories must meet the same high standards. If the factories do not meet certain standards, the FDA won’t allow them to make drugs.
If brand-name drugs and generic drugs have the same active ingredients, why do they look different?
In the United States, trademark laws do not allow generic drugs to look exactly like the brand-name drug. However, the generic drug must have the same active ingredients. Colors, flavors, and certain other parts may be different. But these differences don’t affect the way the drug works and how they are looked at by the FDA.
Does every brand-name drug have a generic drug?
No. When new drugs are first made they have drug patents. Most drug patents are protected for 17 years. The patent protects the company that made the drug first. The patent doesn’t allow anyone else to make and sell the drug. When the patent expires, other drug companies can start selling the generic version of the drug. But first, they must test the drug and the FDA must approve it.
What is the best source of information about generic drugs?
Contact your doctor, pharmacist or other healthcare worker for information on your generic drugs. For more information, you can also visit the FDA website at:
Do generic drugs take longer to work in the body?
No. Generic drugs work in the same way and in the same amount of time as brand-name drugs.
Why are generic drugs less expensive?
Creating a drug costs a lot of money. Since generic drug makers do not develop a drug from scratch, the costs to bring the drug to market are less. But they must show that their product performs in the same way as the brand-name drug. All generic drugs are approved by FDA.
Your medication guide should be kept with you and up to date. List your prescription and over-the-counter medicines as well as your dietary supplements.
|Name of My Medicine||How much do I take?||When do I take it?||What do I use it for?|
|xxxx (Example)||1 Tablet 400 mg||Morning||Arthritis|
Safe. Effective. FDA Approved.
What can you do if your drug is not on the Drug List?
CMS Best Available Evidence
For information about the (BAE) policy please contact member services.
Learn what can you do if you believe you are eligible for Low Income Subsidy but do not have a required piece of evidence
(You will be redirected to this site)
Low Income Subsidy (LIS) Information
Learn how you may be able to get extra help with your prescription drug coverage.
- Low Income Subsidy - English
- Low Income Subsidy - Spanish
- Website Premium Summary Table for Those Receiving Extra Help
Grievance & Appeals
Members and providers who have questions about the Grievance and Appeals processes, need the status of a coverage determination or want to receive an aggregate number of grievance, appeals, and exceptions filed with the plan sponsor, please contact Member Services.
- Coverage Determinations & Appeals, Grievances & Exceptions
- Request For Medicare Prescription Drug Coverage Determination
Appointment of a Representative
The Appointment of Representative Form (PDF, 66 KB) is located on the CMS Web site.
Beneficiaries and providers may appoint another individual, including an attorney, as their representative in dealings with Medicare, including appeals you file. Form CMS-1696, Appointment of Representative form, must be submitted with the appeal and is valid for one year from the date. The form must be signed by both you and the appointed representative. A representative may be designated at any point in the appeals process. This representative may assist you during the processing of a claim or claims and/or any subsequent appeal. Refer to the CMS Medicare Claims Processing Manual (PDF, 605 KB) (Pub. 100-04, chapter 29, section 270.1.10) for information on disclosing information to third parties.
The following types of individuals may be appointed to act as representative for a party to an appeal. This list is not exhaustive and is meant for illustrative purposes only:
- Members of beneficiary advocacy groups
- Members of provider or supplier advocacy groups
- Physicians or suppliers
- Congressional staff members
- Family members of a beneficiary
- Friends or neighbors of a beneficiary
The party making the appointment and the individual accepting the appointment must either complete an appointment of representative form (CMS-1696) or use a conforming written instrument. Refer to the CMS Medicare Claims Processing Manual (Pub. 100-04, chapter 29, section 270.1) for required elements of written instruments. You may appoint a representative at any time during the course of an appeal. The representative must sign the CMS-1696 or other conforming written instrument within 30 calendar days of the date the beneficiary or you sign an order for the appointment to be valid. By signing the appointment, the representative indicates his/her acceptance of being appointed as representative.
The CMS-1696 is available for the convenience of the beneficiary or you to use when appointing a representative. Instructions for completing the form:
- The name of the party making the appointment must be clearly legible. For beneficiaries, the Medicare Health Insurance Claim (HIC) number must be provided.
- Completing Section I - 'Appointment of Representative' - A specific individual must be named to act as representative in the first line of this section. A party may not appoint an organization or group to act as representative. The signature, address and phone number of the party making the appointment must be completed and the date it was signed must be entered. Only the beneficiary or the beneficiary’s legal guardian may sign when a beneficiary is making the appointment. If the party making the appointment is the provider or supplier, someone working for or acting as an agent of the provider or supplier must sign and complete this section.
- Completing Section II - 'Acceptance of Appointment' - The name of the individual appointed as representative must always be completed and his/her relationship to the party entered. The individual being appointed must then sign and complete the rest of this section.
- Completing Section III - 'Waiver of Fee for Representation' - This section must be completed when the beneficiary is appointing a provider or supplier as representative and the provider or supplier actually furnished the items or services that are the subject of the appeal.
- Completing Section IV - 'Waiver of Payment for Items or Services at Issue' - This section must be completed when the beneficiary is appointing a provider or supplier who actually furnished the items or services that are the subject of the appeal and involve issues describe in section 1879(a)(2) of the Social Security Act.
If any one of the elements listed above is missing from the appointment, the adjudicator shall contact the party (individual attempting to act as a beneficiary’s representative) and provide a description of the missing documentation or information. Unless the missing information is provided, the prospective appointed representative lacks the authority to act on behalf of the party and is not entitled to obtain or receive any information related to the appeal, including the appeal decision.
Appointment of Representative Form »
Where to Send This Form
Send this form to the same location where you are sending (or have already sent): (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision.
You can also call the Member Services Department to learn more about how to name your appointed representative.
Drug Utilization Management & Quality Assurance
A major goal as a Medicare Part D contractor is to ensure that our beneficiaries receive safe, high-quality, cost-effective medication therapy. To achieve this goal, Optimum Healthcare, Inc. has entered into a contracted agreement with a claims processor to put certain edits in place to promote appropriate medication therapy. These edits help prevent patients from taking drugs that may have harmful interactions, prevent patients from receiving higher than recommended doses of a medication, notify patients of lower cost alternative medications, and provide other safety and efficacy safeguards.
Optimum HealthCare, Inc has a Clinical Pharmacy Committee that meets regularly to discuss formulary changes, updates to drug edits, and other DUR (drug utilization review) topics. The goal of the Clinical Pharmacy Committee is to improve the quality of care for Optimum HealthCare members through the use of drugs, assuring that the drugs are appropriate, medically necessary, and not likely to result in adverse medical effects. The Clinical Pharmacy Committee will also provide appropriate education and may coordinate with prescribers and pharmacists to identify and reduce the frequency of patterns of fraud, abuse, gross overuse and inappropriate or medically unnecessary care.
Drug Utilization Management
Optimum Healthcare, Inc. requires participating pharmacies to perform a Drug Utilization Review (DUR) before a member receives their prescription. This is designed to analyze drug safety and usage for members based on their total medication profile. The DUR is an important tool that screens online, as the prescription is being filled, for the following potential problems.
- Drug-Drug Interactions
- Drug-Disease Problems
- Drug-Age Precautions
- Drug-Gender Precautions
- Drug-Pregnancy Precautions
- Drug-Allergy Precautions
- Incorrect Dosage Precautions
- Incorrect Duration of Drug Therapy
- Therapeutic Duplication
- Excessive Use Precautions
- Prescription Limitations
- Compliance Monitoring
The drug utilization review serves as a measure to ensure that drug usage criteria are met and satisfy FDA guidelines, and clinical protocols reviewed by our plan’s Clinical Pharmacy Committee, and Medispan’s Criteria. Based on this review, the attending pharmacist and/or physician can make the most beneficial decision for the patient involving their pharmaceutical care.
Optimum Healthcare, Inc. ensures the safety and health of its members through the establishment of effective Quality Assurance measures and systems. We do this to reduce medication errors and adverse drug reactions, and improve medication utilization. These measures include making sure that providers comply with pharmacy practice standards, drug utilization review, internal medication error identification systems, medical therapy management programs, and pharmacy and therapeutics committees. Optimum Healthcare, Inc. also partners with state Quality Improvement Organizations (QIO) that are contracted with Medicare to collect, analyze, and report data based on medication therapy practices.
What to do if you have a problem or complaint about getting a Part D drug?
To learn more about how to ask for an Exception, a Coverage Determination, Appeal or to make a complaint, click on a link below:
- Coverage Determinations & Appeals, Grievances & Exceptions
- Coverage Determination Request Form
- Redetermination Request Form
- Coverage Determination Form at the CMS Website
- Redetermination Form at the CMS Website
- CMS Model Electronic Complaint Form
Pharmacy and Part D Disclaimer
Potential for Contract Termination:
Optimum HealthCare, Inc. has a contract with the Centers for Medicare and Medicaid Services (CMS), the government agency that runs Medicare. This contract renews each year. Optimum HealthCare, Inc. is required to notify beneficiaries that it is authorized by law to refuse to renew its contract with the Centers for Medicare & Medicaid Services (CMS), that CMS also may refuse to renew the contract, and that termination or non-renewal may result in termination of your enrollment. In addition, the plan may reduce its service area and no longer offer services in the area where you reside. In the event this happens, you will receive advance notice.
Rights and Responsibilities upon Disenrollment
Information on aggregate number of grievances, appeals and exceptions
Members can obtain an aggregate number of grievances, appeals and exceptions filed with the plan by calling our customer service department.