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2027 Plan Year Information

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2026 2027

Pharmacy Network, Formulary, and Part D Details

On this page you will find details on the multiple ways you can search our pharmacy network and formulary (drug list). There is also valuable information on Clover Health’s Part D (Prescription) programs and policies, like the Medication Therapy Management Program and Medicare Prescription Payment Plan. 
 

We partner with a network of pharmacies to ensure our plan members can easily access their medications. 

In most cases, your prescriptions are covered only if they are filled at a network pharmacy or through our mail-order pharmacy service. We will fill prescriptions at non-network pharmacies under certain circumstances. These circumstances are described in the Evidence of Coverage (EOC) plan document. You can find the EOC by following this link and entering your zip code to find your plan. 

The formulary is a list of Part D drugs that Clover Health covers for medically necessary purposes, also known as a Drug List. Our comprehensive formulary includes both brand-name and generic drugs that are covered by Clover Health.

Prescription Member Portal by Optum Rx

This is the most comprehensive way to get pharmacy and formulary information. You can visit Optum Open Enrollment Portal. 

For a personalized experience based on your prescription utilization visit My Clover Member Portal. 

Key Highlights

  • Check your plan’s prescription drug list. If a medication isn’t covered, we can help you and your prescriber find a safe and effective alternative.
  • Find a covered pharmacy near you using our locator tool.
  • Watch helpful videos that explain how your plan works.
  • Get answers to frequently asked questions about the transition to Optum Rx.
Visit Optum Rx

Pharmacy Network Directory

Alternatively, you can search for an in-network pharmacy near you at the link below or manually search through our pharmacy network directory in your state. You can also learn more about mail-order, which can save you money on prescriptions.

Visit Optum Rx

Interested in using mail-order pharmacy service? Click here to learn more.

View Clover Pharmacy Network Directory (2027)

Formulary (Drug List) Search

You can find out if your medication is included in the formulary and see which Tier it is in by clicking on the ‘Search Here’ link below. You can see the copay details for each medication Tier for your plan in your Summary of Benefits. You can find the Summary of Benefits by following this link and entering your zipcode to find your plan.

Searching in the Prescription drug list:

2027 Search Here

 

View Clover Formulary PDF (2027)

If Your Drug Isn't Included or Requires Prior Authorization

Clover Health will cover certain drugs as long as members meet specific prior authorization criteria, step therapy criteria, or other formulary requirements. 

If your medication is affected, you have three options: 

Option 1

You can ask your doctor if there's an acceptable alternate medication covered under our formulary.

Option 2

Call our partner in medication services, Optum Rx, to discuss options:

Option 3

Submit an electronic request for Prior Authorization under the Pharmacy Benefits section on the  Prescription Member Portal by OptumRx* available on the My Clover member portal. or download, fill out and fax a form available at Part D Coverage Determinations, Exceptions, Grievances, and Appeals.

*Website access begins on 1/1/2027

Changes to Our Formulary

Clover Health may add or remove drugs from our formulary throughout the year. Here are some possible changes and ways that we’ll keep you informed.

We must alert members taking a certain drug if we make any of these changes:

  • Remove the drug from our formulary
  • Add prior authorization for the drug  
  • Add quantity limits and/or step-therapy restrictions on the drug
  • Move the drug to a higher cost-sharing tier
  • If we're removing a drug from our formulary, we'll either notify affected members 30 days prior to making that change or notify them when they request a refill of that drug (at which time the member will also receive a 30-day supply of the drug).
  • If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we'll immediately remove the drug from our formulary and provide notice to members taking that drug.

Diabetic Testing Supplies

You can get your diabetic testing supplies at a network pharmacy or a durable medical equipment (DME) supplier. Some brands, rules, or approval requirements apply.

If you need help finding a medical equipment supplier, please call Clover Health Member Services at 1-888-778-1478 (TTY users call 711) 8 am to 8 pm local time, 7 days a week.*

To see which brands are covered at a network pharmacy and specific rules that apply, please review: 2027 Covered Diabetic Testing Supplies  

Medication Therapy Management (MTM) Program

Patients with certain chronic conditions who take eight or more prescription medications may be eligible for our Medication Therapy Management (MTM) program, which works with members, doctors and pharmacists to help provide the greatest benefit from their medications.

View Program Details

Need Help with Prescription Costs

How can I lower my drug costs?

Medicare Part D Claim Form (Reimbursement)

Medicare Prescription Payment Plan (M3P)

 

Quick Tip!

For an easy claim submission process and a faster claim decision, submit requests for reimbursement of member-paid prescriptions online using the link for Claim Reimbursement.

Related Information

Prescription Drug Transition Policy

Quality Assurance and Drug Management Programs

Centers for Medicare and Medicaid Services (CMS): Best Available Evidence (BAE) Documentation

For more information about any of the forms, contact our Member Services Team at 1-888-778-1478 (TTY 711) 8 am to 8 pm local time, 7 days a week.*