Prescription Claim Form [pdf, 882 KB] Prescription Mail Service Order Form [pdf, 1155 KB] If your policy has a mail-order drug benefit, use this form to order new and/or refill mail service prescriptions.Prior Authorization Form for Prescription Drugs [pdf, 125 KB]
2016 Standard Formulary [pdf, 1231 KB] 2016 Maintenance Drug List [pdf, 313 KB] 2016 Metallic Comprehensive Formulary [pdf, 4893 KB] 2016 Standard with Step Therapy Formulary (Formerly known as Value Formulary) [pdf, 1523 KB] Prior Authorization List [pdf, 49 KB] Medications that require prior approval. For authorization, call 1-877-433-2973.2016 Standard/ Standard with Step Therapy Formulary Non-Covered Medications with Covered Alternatives [pdf, 348 KB]
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