Language Assistance Available [pdf, 561 KB] Prescription Claim Form [pdf, 823 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, 1393 KB] 2016 Maintenance Drug List [pdf, 751 KB] 2016 Metallic Formulary [pdf, 3936 KB] 2016 Standard with Step Therapy Formulary (Formerly known as Value Formulary) [pdf, 1483 KB] 2017 Standard Formulary [pdf, 1393 KB] 2017 Metallic Formulary [pdf, 3876 KB] 2017 Standard with Step Therapy Formulary [pdf, 1484 KB] 2017 Standard with Step Drug List [pdf, 1083 KB] Prior Authorization List [pdf, 611 KB] Medications that require prior approval. For authorization, call 1-877-433-2973.
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