Rx Search

Directories of drug formularies for health plans participating in the CaliforniaChoice® Program

This directory of drug formularies was collected from all plans participating in the CaliforniaChoice program and is accurate to the best of our knowledge at the time the data was posted to the website. However, the drug formularies and policies offered through CaliforniaChoice health plans may change at any time without notice. Keep in mind, this is only a guide and you must verify the information directly with the health plan only before making decisions based on the information provided in this directory. CaliforniaChoice will not be responsible for the information presented in this search.

Click here for Cigna + Oscar's formulary list

For questions, call Customer Service at (800) 558-8003.

About This Data

The information provided in the CA Internet Formulary reference is provided by Managed Markets Insight & Technology, LLC (“MMIT”). MMIT provides similar information in its CA Managed Care Formulary guide to practicing physicians in California.

The data contained in the CalChoice Internet Formulary Reference is provided by the health care organizations that are included behind the Listing of Plans menu item. The Site provides the formulary status for more than 600 pharmaceutical products. The fact that a drug is not included in this site does not necessarily mean that it is not on a particular managed care formulary. MMIT assembles the data into a standardized data set contained as a subset of the MMIT Formulary database, a national database of formularies for over 1100 managed care organizations. Once standardized, the information is accumulated and published in books or web sites such as this.

MMIT specializes in collecting and interpreting formulary information for the health care industry. MMIT employs professional pharmacists to manage the formulary data interpretation and data entry processes. The data provided here is regularly updated as changes are received from the CA health care organizations. The information is valid through the dates shown under the valid date column.


Public Domain Data Copyright

Formulary information is classified as public domain information. It cannot be owned by any party including the health plans that provide it. It can be formatted in certain published formats and protected under US copyright law. The information on this web site consists of pre-existing facts. Some of the information contained in this database is also available on individual plan web sites. Some of the information contained in the MMIT database but not necessarily in this data set is obtained from such public sites.

All of the information provided here is selected and formatted by using MMIT's formatting and in such formats is protected under MMIT copyrights.
 

Plan Information

This is a list of organizations (HMO plan or medical group) that publishes the formulary appearing under their name. The member services phone number is presented for the user's convenience. Please refer to the Effective Date and Valid Date which explain these two columns.


Information Dates

Formularies are dynamic. They are continuously changing as new drugs are added and old drugs are deleted, as plans add or change benefits and when some plans are bought or merged into others. Also, drugs may remain in a formulary but change status from time to time.

MMIT receives notice from the plans at about the same time as physicians do. However, in an effort to maintain the best information, MMIT checks with the listed CA plans on a monthly basis to be sure we have the latest information. There is no fixed schedule to these changes! There may be several changes at one time or no changes for several months. The schedules provided here match the information given to your physicians by these Health Care organizations. MMIT cannot guarantee and does not warrant the accuracy or completeness of this formulary information.


Accuracy

It is our intention to provide data that is as accurate as possible. As there is no industry standard for Drug statuses, the information contained here is subject to interpretation. For instance, what one plan may call a preferred drug another may call Approved. MMIT strives to standardize the information to the following interpretation.

 
Status Symbol(s) Interpretation
Preferred preferred.gif Preferred over all other drugs in the same therapeutic category.
Approved approved.gif Approved for reimbursement without any restrictions.
Prior Authorization priorauth.gif Reimbursement will be allowed only when the claim has been submitted to plan officials by a prescriber for review prior to the issuance of a prescription.
Non-Formulary nonform.gif The Plan lists this drug as not on the formulary. Please click on the policy_icon.gif icon to review the Plan's Benefits/Policies regarding non formulary drugs.
Not Reimbursed notreimb.gif This drug is not reimbursed by the plan.
Not Listed notlisted.gif No information available for this drug. It may or may not be reimbursable.
Benefits/Policies policy_icon-(1).gif Click the icon to view the Plan's Benefits/Policies.
Generic Available generic.gif The generic-(1).gif symbol indicates that the drug name it appears after is available as a generic equivalent. Health insurance providers almost always require that a generic be used if it is available.
Notes or Restrictions NOTES.gifNOTES_restrict.gif Click the icon to view the Plan's notes or restrictions.

 

Frequently Asked Questions

 

What is a formulary?
A formulary is a list of prescription drugs that a health plan has approved for use by doctors. Health plans that have formularies develop their own unique list of "approved" drugs. Formularies may change at any time.

Health plans may only pay for medications that are on this "approved" list, unless your doctor goes through the health plan's Prior Authorization process.
What if my doctor wants to prescribe a non-formulary medication?
Your doctor may prescribe a prescription drug that is not on your health plan's formulary; in that case you may have to pay the full price for the medication when you pick it up at the pharmacy.

Your doctor may be able to obtain "prior authorization" from the health plan to prescribe a non-formulary drug. This typically requires that your doctor contact the plan either in writing or on the telephone and make the case for a non-formulary drug. This process can be time consuming and if successful, you will have to obtain authorization every 30 days for refills.
Why does my health plan have a formulary?
Health plans use formularies to control the cost of pharmaceutical health care. There are various approaches as to how plans will implement control. Some will use "closed" formularies that restrict which drugs a plan will pay for and which it will not. Others will use "open" formularies but include different co-pay levels. Others will use guidelines and protocols to encourage physicians to prescribe according to a predetermined therapeutic strategy developed by the plan's health professionals. And sometimes a formulary will include a mixture of these approaches.

Formularies differ between health plans and you should compare availability of medications before making a choice of health plan.
What is a generic drug? Is it safe to take it instead of the brand name drug?
A generic drug is a copy of the original drug that is no longer protected by a U.S. patent. It is typically a drug that has been available for more than 10 years. Generic drug manufacturers are allowed to produce these drugs after the patent for the original has expired. Generic drugs are usually (not always) less expensive than brand drugs, since generic manufacturers haven't had to invest in the research and development of the drug when it was brought to market.

Substituting a generic drug for a brand-name drug usually has no adverse effect. For a few, there could be unintended side effects. If you find that you are having a problem with a generic drug, your doctor may switch your prescription to a branded drug at any time. Plans that recommend generic drugs almost always also cover brand name drugs that can be used for the same therapy. Check with your doctor before switching between brand name and generic drugs.
How often is the information updated?
The information on this site is regularly updated to reflect the continuous changes in formularies. The frequency depends upon the number of changes being reported by the managed care organizations. That typically means three or four updates per year.
What is a therapeutic class and subclass?
Therapeutic classes are used to categorize or group the drugs on the formulary. The classes group drugs which are considered similar by the disease they treat or by the effect they have on the body. Therapeutic subclasses further categorize the drugs into smaller groupings.
What is a formulary status?
A formulary "status" is the means used by health plans to distinguish between drugs on the formulary. Your doctor uses these statuses to interpret the recommendations of the P&T Committee. InfoScan has developed a standardized set of statuses as used on this site to insure that the drugs are being classified using the same terminology for all plans. InfoScan's statuses are explained in the About This Data section of the main menu.
What is Prior Authorization?
A health plan may give certain drugs a status of Prior Authorization (PAR) priorauth.gif. If your doctor wants to prescribe a PAR drug for you, he or she must follow the plan's procedure before the drug can be dispensed as a covered benefit. In most cases, the procedure includes filling out a request form which is then addressed by the P&T Committee or pharmacy staff responsible for evaluating requests. This process maybe time consuming and if successful, you may have to obtain authorization every 30 days for refills.
How do I compare coverage for a drug between plans?
The easiest way to compare drug coverage between plans is to use the search menu. You can search by brand name or generic name. Click on the drug name. A list of all the plans in the database will appear and provide you with the status of your drug by plan. A key is available which explains the icons.
Does my doctor have these formularies?
Yes. Your health plan sends it's affiliated doctors a copy of their plan formulary. InfoScan sometimes publishes plan formulary books. In California we also publish the Triple i CA Managed Care Formulary Guide which is sent free to approximately 24,000 California physicians. Also, this site can be used by doctors to review drug statuses.
What if my drug is not listed?
There are a number of reasons the drug may have a "not listed" status. You will need to check with your plan for information about that drug or their policy for not listed drugs. You may sometimes find an explanation attached for a not listed drug by clicking on the note icon, if one is located next to the notlisted.gif symbol.
How can I find out if my drug is listed?
From the search menu, on the letter of the alphabet that corresponds to the first letter of the drug you are seeking. This will give you a list of drug names to pick from. Scan the list and click the one you are interested in reviewing. The table will display the drug for all the plans in California.
A drug I'm interested in is listed twice. What does that mean?
The drug is in two different therapeutic classes or subclasses. Your drug can be prescribed for more than one disease or condition. You will need to look at the appropriate therapeutic class for your condition to find the status. Statuses can differ between therapeutic classes. For instance, a drug can be preferred in one class and approved in another class.
Are all unlisted drugs reimbursed if there isn't a not reimbursed symbol?
Not necessarily. You will need to check with your health plan to ensure they will reimburse you for a drug not on their formulary. In general, if the drug has a status of "approved" or "preferred", it will be reimbursed. If the drug has a status of "non-formulary" or "prior authorization", it may be reimbursed as usual, at a different rate or not at all.
If my drug is not reimbursed, does that mean I cannot get it?
No. Doctors can prescribe any medication they choose. However, if the drug is not listed on the formulary and you cannot obtain it through the plan's prior authorization process, you may have to pay the total cost of the medication.

 

Listing of Plans

EFFECTIVE 7/1/21 FOR NEW AND RENEWING GROUPS:
 
Plan Name Member Services Number
Anthem Blue Cross HMO and PPO (855) 383-7248
Cigan + Oscar (855) 672-2755
Health Net (800) 361-3366
Kaiser Permanente (800) 464-4000
Oscar (855) 672-2755
Sharp Health Plan (800) 359-2002
Sutter Health Plus (855) 315-5800
UnitedHealthcare (800) 624-8822
Western Health Advantage (888) 563-2250
  

EFFECTIVE 1/1/21 FOR NEW AND RENEWING GROUPS:
 
Plan Name Member Services Number
Anthem Blue Cross HMO and PPO (855) 383-7248
Health Net (800) 361-3366
Kaiser Permanente (800) 464-4000
Oscar (855) 672-2755
Sharp Health Plan (800) 359-2002
Sutter Health Plus (855) 315-5800
UnitedHealthcare (800) 624-8822
Western Health Advantage (888) 563-2250