Have questions about which medications are covered by your plan? Access your formularies here or search a drug via the search tool.
List of Drugs (Formulary): Updated September 3, 2024
List of Drugs Change Notice: Updated February 1, 2024
Notice of Change
Prior Authorization Criteria: Updated September 3, 2024
Step Therapy Criteria: Updated October 15, 2023
Prescription Drug Claim Form
Complete this form to request reimbursement for covered prescription drugs that you paid full price for.
Express Scripts® Mail Order Form
Members can complete this form to order prescriptions from Express Scripts® Pharmacy.
Covered Diabetes Testing Supplies
Preferred diabetes testing supplies list (blood glucose meters and test strips) you can receive from an in-network pharmacy for plan year 2024.
Prescription Drug Coverage and Your Rights
This document outlines your rights with regards to your Medicare drug plan.
Request for Medicare Prescription Drug Coverage Determination
Complete this printable form to ask us for a decision about a prescription drug and your specific plan coverage. Members should fax form to 1-866-388-1767.
Request for Redetermination of Medicare Prescription Drug Denial (Appeal)
Complete this printable form to ask for an appeal after being denied a request for coverage or payment for a prescription drug. Members should fax form to 1-866-388-1766.