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



Requestor Information



Additional Information  

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

Other Health Information



Drug Information  


Summary Of Request

Contact Us
New Medi-Cal Members
Forms and Documents

Download the free Adobe Reader.

Materials available on this website in PDF format may require the free Adobe Reader to view. To download Adobe Reader for free from the Adobe website, click here.