Pharmacy Part D Coverage Information

2017 Formulary Information Formulary FAQ Pharmacy Network Information
Appointment of a Representative Generic Drugs Prior Authorization Criteria
CMS Best Available Evidence Grievance & Appeals Step Therapy Criteria
Drug Utilization Management & Quality Assurance Low Income Subsidy Information Transition Policy
Drugs with Quantity Limits Medication Therapy Management Coverage Determination Request Form
Formulary Changes Part D Drug Problems or Complaints Redetermination Request Form

Access our Pharmacy System

Members can register and login to our Pharmacy Benefit Manager (PBM) system by going to This site allows members to search for pharmacy locations, price pharmacy claims, order mail order refills, determine generic availability for your medication, 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. has 4,134 pharmacies their network. These pharmacies are contracted through our Pharmacy Benefit Administrator, Spectral Solutions.

We also list 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. Hours are October 1 to February 14 from 8 a.m. to 8 p.m. 7 days a week and February 15 to September 30 from 8 a.m. to 8 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. Select your "County" and "Provider Type" then click on the “Search Now” button.

2017 Formulary Information (List Of Covered Drugs)

A formulary is a list of drugs covered by your plan to meet patient needs.
To search for a drug, click on the link below. Once the page is opened, select your county and plan then type in your drug name or drug category in the “Search” box. You can even download the Formulary in a PDF version.

Formulary Changes

Formulary list may change during the year. Updates, if any, will be posted monthly. Click here 

Formulary FAQs

Prior Authorization Criteria

Step Therapy Criteria

Click here to learn which drugs must meet Step Therapy Criteria. 

Drugs with Quantity Limits

Click here to find out about drugs with Quantity Limits. 

Generic Drugs

Click here to learn more about generic drugs. 

Transition Policy

What can you do if your drug is not on the Drug List?
English  |  Spanish 

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.

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.

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:

  • Congressional staff members
  • Family members of a beneficiary
  • Friends or neighbors of a beneficiary
  • Members of beneficiary advocacy groups
  • Members of provider or supplier advocacy groups
  • Attorneys
  • Physicians or suppliers

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:

  1. The name of the party making the appointment must be clearly legible. For beneficiaries, the Medicare Health Insurance Claim (HIC) number must be provided.
  2. 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.
  3. 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.
  4. 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.
  5. 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. The adjudicator will not dismiss the appeal request because the appointment of representative is not valid.

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. uses a Pharmacy and Therapeutics committee which is responsible for the establishment and implementation of medical standards and criteria for the concurrent and retrospective DUR (Drug Utilization Review) programs. It is the goal of the Pharmacy and Therapeutics committee to improve the quality of care for Optimum Healthcare, Inc. members through the use of drugs, assuring that the drugs are appropriate, medically necessary, and not likely to result in adverse medical effects. The Pharmacy and Therapeutics committee is charged with making recommendations for educational interventions to 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 as adopted by our plan’s Pharmacy and Therapeutic Committee, and Medispan’s Criteria. Based on this review, the attending pharmacist and/or physician can make the most beneficial decision to the patient involving their pharmaceutical care.
Quality Assurance 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:

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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.

Last Updated: 10/28/2016