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]
2015 Standard Formulary [pdf, 1357 KB] 2015 Essential Formulary [pdf, 988 KB] 2015 Metallic Comprehensive Drug List [pdf, 3382 KB] 2015 Metallic Drug List [pdf, 231 KB] 2015 Value Formulary [pdf, 1335 KB] 2016 Standard Formulary [pdf, 1128 KB] 2016 Value Formulary [pdf, 1297 KB] 2016 Essential Value Formulary [pdf, 1085 KB] 2016 Metallic Comprehensive Formulary [pdf, 2136 KB] Maintenance Drugs [pdf, 194 KB] Medications considered to be necessary for long periods of time.Prior Authorization List [pdf, 59 KB] Medications that require prior approval. For authorization, call 1-877-433-2973.2016 Standard/Value Formulary Non-Covered Medications with Covered Alternatives [pdf, 348 KB]
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