Pharmacy Benefits: Optum Rx Replaced by CVS Caremark

In most cases, you’ll continue to order prescriptions at your preferred retail pharmacy (e.g., CVS, Walgreens, Safeway, VONS, etc.). However, there may be some changes to the list of covered drugs or changes to in-network pharmacies. Additionally, mail order prescriptions and specialty pharmacy prescriptions will be dispensed through CVS Caremark pharmacies, instead of OptumRx pharmacies.

Some medications may have different approval requirements under the new PBM. If you currently have an active approved prior authorization, it’ll transfer automatically to CVS.

Yes. The mail order pharmacy will change, but mail order delivery will continue to be an option. Most mail order prescriptions will transfer automatically, and you’ll receive instructions on how to place your first order.

Many prescriptions transferred automatically to the new mail order pharmacy (CVS Caremark). Some medications may require a new prescription from your doctor, such as controlled substances or expired refills. You’ll be notified if action is needed.

Yes. You’ll need to provide your new ID card to the pharmacy.

Your physician can request a medical necessity exception for your medication if it’s no longer covered but they believe it’s the most effective medication for your condition.

Yes. Specialty medications are now filled through CVS specialty pharmacies.

If impacted, you should have received detailed information approximately 30-60 days prior to the effective date of January 1, 2026.

The formulary and exclusions lists, as well as CVS’s formulary search tool, for Basic plans and Medicare are available now:

• Basic Plan Formulary (PDF)
• Basic Plan Exclusions (PDF) – list of medications no longer covered on the Basic formulary as of January 1, 2026. For all excluded drugs, safe and effective alternatives are available.
• Medicare Plan Formularies (formularies are the same across Medicare plans; however, lists are separated for ease of reference)
  • Anthem Blue Cross Medicare Preferred (PDF)
  • PERS Gold Medicare Supplement (PDF)
  • PERS Platinum Medicare Supplement (PDF)
• Additional Coverage (PDF) - list of medications covered by CalPERS that are not included in the Medicare Plan formulary (Lists are the same across the Medicare plans.)
• Medicare Exclusions (PDF) – list of medications no longer covered on the Medicare formulary as of January 1, 2026. These exclusions apply to all SilverScript-covered Medicare plans. For all excluded drugs, safe and effective alternatives are available.

There may be updates to the formulary, including changes to covered medications. If your medication is impacted, you’ll be notified by mail and provided additional information, including alternative options, to discuss with your doctor.

Yes. All excluded medications have an equally safe and effective alternative medication on the new formulary.

It’s possible that some medications changed tiers in the new formulary which result in changes to copayments.

A formulary change refers to modifications made to the list of covered prescription drugs, known as the formulary. These changes can involve adding, removing, or reclassifying drugs, as well as adjusting prior authorization or step therapy requirements.

If your medication is affected by a formulary change – for example, no longer covered or moved to a higher tier, you should have received a personalized letter approximately 30-60 days before the January 1, 2026. This letter included:

• Covered alternatives
• Next steps if you need to request a formulary exception
• How to speak with your doctor about switching medications

A Prior Authorization is a standard administrative process when your prescription insurance needs to review and approve a medication before it will be covered. Your doctor submits a request, and the insurance company checks that it meets their coverage rules like being used for the right condition, following required steps, and being safe. This helps ensure the medication is appropriate for you.

A Medical Necessity is when your prescription insurance needs an explanation from your doctor about why you need a specific medication. It shows that the treatment is medically necessary for your condition based on your health history and medical guidelines. This information is often required when asking for approval, filing an appeal, or requesting an exception.

A Formulary Exception is a request to have your insurance cover a medication that is not on their formulary.  You doctor must show that the requested medication is medically necessary for your condition based on your health history and medical treatment guidelines.  Your doctor must include medical information to show that other covered options have not worked, caused side effects, or are not right for you.  This information is often required when asking for approval or filing an appeal.

A Tier Exception is a request to lower your copay. Your doctor must show that you need the medicine based on your health history and treatment guidelines. Your doctor also needs to include medical details showing that other covered drugs within a lower tier did not work, caused side effects, or are not safe for you. This information is often needed when asking for approval or making an appeal. 

You can only ask for a Tier Exception if your medication is on the formulary (the list of covered drugs).