2019 Gold (HMO) Pharmacy Documents (English/Spanish)

You can choose from 60,000 pharmacies nationwide and over 600 pharmacies in our service area. Golden State Medicare Health Plan has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. This plan offers national in-network prescription coverage. We have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan. In most cases, you need to get your prescription (as well as your other care) from a provider in the plan’s provider network.

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Pharmacy (Rx) & Provider Directory (Los Angeles & Orange County)

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Pharmacy (Rx) & Provider Directory (Riverside)

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Pharmacy (Rx) & Provider Directory (Stanislaus)

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Pharmacy (Rx) & Provider Directory (San Luis Obispo)

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Pharmacy (Rx) & Provider Directory (Contra Costa)

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Drug Formulary, San Luis Obispo and Contra Costa Counties

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Drug Formulary, Los Angeles, Orange, Riverside and Stanislaus Counties

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Mail Order Form

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Prior Authorization

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Step Therapy

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Medication Therapy Management Program

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Drug Reimbursement Form

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Part D Coverage Determination Request (Member/Provider)

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Drug Transition Notice

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How to Request an Exception

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Extra Help / Low Income Subsidy

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Appeals Process

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Grievance Process

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Part D Coverage Decisions and Appeals

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What types of drugs are NOT covered by the plan?

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CMS Best Available Evidence (BAE) Policy


* Adobe Acrobat Reader is required to view PDF files. This is a free program available from the Adobe Website HERE.

The Formulary, pharmacy network, and provider network may change at any time. You will receive notice when necessary. Please refer to the Evidence of Coverage document for detailed information on the following topics: Description of Part D Drug coverage, Exceptions to our network coverage, Mail-Order service, Long-term supply of drugs, Cost sharing tiers, Restrictions, Coverage changes, Formulary updates, Drug safety, Drugs not covered by the plan, Drug payment stages, Explanation of Benefits, Drug Costs, Coverage Gap, Catastrophic Coverage, Vaccine Coverage, Late Enrollment Penalty, Grievance, Coverage Determinations and Appeals, Medication Therapy Management (MTM) program, Contract termination, Member rights and responsiblities.

This information is available for free in other languages. Please contact our customer service number at (877) 541-4111 or TTY at (877) 551-4111 from 8 a.m. to 8 p.m. Monday through Friday and daily during the enrollment period.

Esta información está disponible de forma gratuita en otros idiomas. Por favor, póngase en contacto con nuestro número de servicio al cliente al (877) 541-4111 o TTY al (877) 551-4111 de 8 am a 8 pm de lunes a viernes, y todos los días durante el período de inscripción.

Updated 5/3/2019