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Formulary Links, Forms and Contacts

Anthem (MediBlue Enhanced, MediBlue Rx Plus, MediBlue Rx Standard)

Anthem Website [1]

Formularies (drug lists):

MediBlue Enhanced [2]

MediBlue Rx Plus [3]

MediBlue Rx Standard [4]

Prior Authorization Criteria, Step Therapy Requirements:

MediBlue Enhanced: Prior Authorization Criteria [5] and Step Therapy Requirements [6]

MediBlue Rx Plus: Prior Authorization Criteria [7] and Step Therapy Requirements [8]

MediBlue Rx Standard: Prior Authorization Criteria [9] and Step Therapy Requirements [10]

Coverage Determination Form [11]

Coverage Determination (Prior Authorization) Phone: 1-833-293-0661 [12]  (TTY 711)

Coverage Determination (Prior Authorization) Fax: 1-844-521-6938

Redetermination (First Level Appeal) Form [13]

Redetermination (First Level Appeal) Phone:  1-866-755-2776 [14]  (TTY 711)

Redetermination (First Level Appeal) Fax: 1-888-458-1407

Expedited Redetermination (First Level Appeal) Phone:  1-866-755-2776 [14]  (TTY 711)

Customer Service Line (Members): 1-866-755-2776 [14]  (TTY 711)

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Cigna-Healthspring Rx (Secure Rx, Secure-Extra Rx, Secure-Essential Rx)

Cigna-Healthspring Website [15]

Formularies (drug lists):

Secure Rx Plan [16]

Secure-Extra Rx Plan [17]

Secure-Essential Rx Plan [18]

Coverage Determination (Prior Authorization) Form [19]

Prior Authorization Criteria, Step Therapy Requirements

Secure Rx:  Prior Authorization Criteria [20] and Step Therapy Requirements [21]

Secure-Extra Rx:  Prior Authorization Criteria [22] and Step Therapy Requirements [23]

Secure-Essential Rx:  Prior Authorization Criteria [24] and Step Therapy Requirements [25]

Coverage Determination (Prior Authorization) Phone: 1-877-813-5595 [26]

Coverage Determination (Prior Authorization) Fax: 1-866-845-7267

Redetermination (First Level Appeal) Form [27]

Redetermination Appeal Phone:  1-866-845-6962 [28]

Redetermination Appeal Fax: 1-866-593-4482

Expedited Redetermination Appeal Phone: 1-866-845-6962 [28]

Customer Service (Members): 1-800-997-1654 [29] (TTY/TDD 711)

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Elixir (Rx Plus, Rx Secure Plans)

Elixir Website

Formularies (drug lists):

Elixir Rx Plus [30]

Elixir Rx Secure [31]

Coverage Determination (Prior Authorization) Form [32]

Elixir Rx Plus:  Prior Authorization Criteria [33], Step Therapy Requirements [34], and Quantity Limits Criteria [35]

Elixir Rx Secure:  Prior Authorization Criteria [36], Step Therapy Requirements [37], and Quantity Limits Criteria [38]

Coverage Determination (Prior Authorization) Phone: 1-866-250-2005 [39] (TTY/TDD 711)

Coverage Determination (Prior Authorization) Fax: 1-877-503-7231

Redetermination (First Level Appeal) Form [40]

Redetermination (First Level Appeal) Fax: 1-877-503-7231

Expedited Redetermination (First Level Appeal) Phone: 1-866-250-2005 [39]

Customer Service Phone (Members): 1-866-250-2005 [39] (TTY/TDD 711)

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Express Scripts Medicare (Value, Choice, Saver Plans)

Express Scripts Website [41]

Formularies (drug lists):

Value Plan [42]

Choice Plan [43]

Saver Plan [44]

Coverage Determination Form [45]

Prior Authorization Criteria, Step Therapy Requirements

Value Plan:  Prior Authorization Criteria [46] and Step Therapy Requirements [47]

Choice Plan:  Prior Authorization Criteria [48] and Step Therapy Requirements [49]

Saver Plan:  Prior Authorization Criteria [50] and Step Therapy Requirements [51]

Coverage Determination (Prior Authorization) Phone: 1-844-374-7377 [52] (TTY/TDD 1-800-716-3231 [53])

Coverage Determination (Prior Authorization) Fax: 1-877-251-5896

Redetermination (First Level Appeal) Form [54]

Redetermination Appeal Phone: 1-844-374-7377 [52] (TTY 1-800-716-3231 [53])

Redetermination Appeal Fax: 1-877-852-4070

Customer Service Phone (Members): 1-866-477-5703 [55] (TTY 1-800-716-3231 [53])

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Humana (Basic, Premier, Walmart Value Plans)

Humana Website [56]

Formularies (Drug Lists):

Basic Plan [57]

Premier Plan [58]

Walmart Value Plan [59]

Coverage Determination Form [60]

Prior Authorization Criteria, Step Therapy Requirements

Basic Plan:  Prior Authorization Criteria [61] and Step Therapy Requirements [62]

Premier Plan:  Prior Authorization Criteria [63] and Step Therapy Requirements [64]

Walmart Value Plan:  Prior Authorization Criteria [65] and Step Therapy Requirements [66]

Coverage Determination (Prior Authorization) Phone: 1-800-555-2546 [67]

Coverage Determination (Prior Authorization) Fax: 1-877-486-2621

Redetermination (First Level Appeal) Form [68]

Redetermination Appeal Phone:  1-877-320-1235 [69]

Redetermination Appeal Fax:  1-888-556-2128

Expedited Redetermination Appeal Phone:  1-877-320-1235 [69]

Expedited Redetermination Appeal Fax:  1-888-556-2128

Customer Service Phone: 1-800-457-4708 [70] (TTY 711)

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Mutual of Omaha (Rx Plus, Rx Value Plans)

Mutual of Omaha Website [71]

Formularies (Drug Lists):

Rx Plus [72]

Rx Premier [73]

Coverage Determination Form [74]

Prior Authorization Criteria, Step Therapy Requirements

Rx Plus: Prior Authorization Criteria [75] and Step Therapy Requirements [76]

Rx Premier: Prior Authorization Criteria [77] and Step Therapy Requirements [78]

Coverage Determination (Prior Authorization) Phone: 1-800-935-6103 [79]

Coverage Determination (Prior Authorization) Fax: 1-877-251-5896

Redetermination (First Level Appeal) Form [80]

Redetermination Appeal Phone:  1-800-935-6103 [79]

Redetermination Appeal Fax: 1-877-328-9660

Expedited Redetermination Appeals can be done by phone: 1-800-935-6103 [79]

Customer Service Phone: 1-855-864-6797 [81] (TTY: 1-800-716-3231 [53])

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Silverscript (Choice, Plus Plans)

Silverscript Website [82]

Formularies (Drug Lists):

Choice Plan [83]

Plus Plan [84]

Smart Rx Plan [85]

Coverage Determination Form [86]

Prior Authorization Criteria, Step Therapy Requirements

Choice Plan:  Prior Authorization Criteria [87] and Step Therapy Requirements [88]

Plus Plan:  Prior Authorization Criteria [89] and Step Therapy Requirements [90]

Smart Rx Plan:  Prior Authorization Criteria [91] and Step Therapy Requirements [92]

Coverage Determination (Prior Authorization) Phone: 1-800-414-2386 [93]

Coverage Determination (Prior Authorization) Fax: 1-800-408-2386

Redetermination (First Level Appeal) Form [94]

Redetermination Appeal Phone:  1-866-235-5660 [95] (TTY: 711)

Redetermination Appeal Fax: 1-855-633-7673

Expedited Redetermination (First level Appeal) Phone: 1-866-235-5660 [95] (TTY: 711)

Customer Service Phone:  1-855-335-1407 [96] (TTY: 711)

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United Healthcare (AARP Preferred, AARP Saver Plus, AARP Walgreens)

United Healthcare Website [97]

Formularies (drug lists):

AARP Preferred [98]

AARP Saver Plus [99]

AARP Walgreens [100]

Prior Authorization Criteria, Step Therapy Requirements:

AARP Preferred:  Prior Authorization Criteria [101] and Step Therapy Requirements [102]

AARP Saver Plus:  Prior Authorization Criteria [103] and Step Therapy Requirements [104]

AARP Walgreens:  Prior Authorization Criteria [105] and Step Therapy Requirements [106]

Coverage Determination Form [107]

Coverage Determination (Prior Authorization) Phone:  1-800-711-4555 [108]

Coverage Determination (Prior Authorization) Fax:  1-844-403-1028

Redetermination (First Level Appeal) Form [109]

Redetermination (First Level Appeal) Phone:  1-800-595-9532 [110]

Redetermination (First Level Appeal) Fax:  1-866-308-6294

Expedited Redetermination (First Level Appeal) Phone:  1-800-595-9532 [110]

Customer Service (Members):  1-800-556-7596 [111]

back to top of page [112]

WellCare (Classic, Rx Saver, Rx Select, Rx Value Plus, Value Script, Wellness Rx Plans)

WellCare Website

Formularies (Drug Lists):

Classic [113]

Rx Saver [113]

Rx Select [114]

Rx Value Plus [115]

Value Script [116]

Wellness Rx [116]

Coverage Determination Form [117]

Coverage Determination (Prior Authorization) Phone: 1-888-550-5252 [118]

Coverage Determination (Prior Authorization) Fax: 1-866-388-1767

Redetermination (First Level Appeal) Form [119]

Redetermination (First Level Appeal) Phone:  1-888-550-5252 [118]

Redetermination Fax: 1-866-388-1766

Expedited Redetermination Phone: 1-888-550-5252 [118]

Customer Service Phone: 1-888-550-5252 [118]

Pharmacy Provider Phone: 1-888-550-5252 [118]

 

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MaineCare Member Services: 1-855-797-4357 [120]

The MaineCare site has MaineCare/DEL Formularies [121] and Prior Authorization Forms [122] (not Medicare Part D).

The CMS website has a [123]standard form for coverage determinations [124](prior authorizations), scroll down to "Downloads" and click on "Model Coverage Determination Request Forms and Instructions". This form can be used with any Medicare Part D Plan.

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Updated October 2019

Links
[1] https://www.anthem.com/medicare/medicare-part-d/
[2] https://file.anthem.com/MED2021/Y0114_21_123977_I_C_0016.pdf
[3] https://file.anthem.com/MED2021/Y0114_21_123977_I_C_0020.pdf
[4] https://file.anthem.com/MED2021/Y0114_21_123977_I_C_0014.pdf
[5] http://file:///C:/Users/LACHAP~1.025/AppData/Local/Temp/2/RXFLEX-PRIOR-AUTHORIZATION-ALL-PDFS-PDP-ENHANCED-ALTERNATIVE.pdf
[6] http://file:///C:/Users/LACHAP~1.025/AppData/Local/Temp/2/RXFLEX-STEP-THERAPY-ALL-PDFS-PDP-ENHANCED-ALTERNATIVE.pdf
[7] http://file:///C:/Users/LACHAP~1.025/AppData/Local/Temp/2/RXFLEX-PRIOR-AUTHORIZATION-ALL-PDFS-PDP-PLUS.pdf
[8] http://file:///C:/Users/LACHAP~1.025/AppData/Local/Temp/2/RXFLEX-STEP-THERAPY-ALL-PDFS-PDP-PLUS.pdf
[9] http://file:///C:/Users/LACHAP~1.025/AppData/Local/Temp/2/RXFLEX-PRIOR-AUTHORIZATION-ALL-PDFS-PDP-BASIC.pdf
[10] http://file:///C:/Users/LACHAP~1.025/AppData/Local/Temp/2/RXFLEX-STEP-THERAPY-ALL-PDFS-PDP-BASIC.pdf
[11] http://file:///C:/Users/LACHAP~1.025/AppData/Local/Temp/2/2020+Coverage+Determination+Request+Form_0001+ABS_wcag.pdf
[12] tel:1-833-293-0661
[13] http://file:///C:/Users/LACHAP~1.025/AppData/Local/Temp/2/2020+Redeterm+Req+Form_0010+ABS+PDP_wcag.pdf
[14] tel:1-866-755-2776
[15] https://www.cigna.com/medicare/part-d/
[16] https://www.cigna.com/static/www-cigna-com/docs/medicare/plans-services/2021/formulary-secure-en.pdf
[17] https://www.cigna.com/static/www-cigna-com/docs/medicare/plans-services/2021/formulary-secure-extra-en.pdf
[18] https://www.cigna.com/static/www-cigna-com/docs/medicare/plans-services/2021/formulary-secure-essential-en.pdf
[19] https://www.cigna.com/static/www-cigna-com/docs/medicare/plans-services/2021/pdp-determination.pdf
[20] https://www.cigna.com/static/www-cigna-com/docs/medicare/plans-services/2021/prior-authorization-secure.pdf
[21] https://www.cigna.com/static/www-cigna-com/docs/medicare/plans-services/2021/step-therapy-secure.pdf
[22] https://www.cigna.com/static/www-cigna-com/docs/medicare/plans-services/2021/prior-authorization-secure-extra.pdf
[23] https://www.cigna.com/static/www-cigna-com/docs/medicare/plans-services/2021/step-therapy-secure-extra.pdf
[24] https://www.cigna.com/static/www-cigna-com/docs/medicare/plans-services/2021/prior-authorization-secure-essential.pdf
[25] https://www.cigna.com/static/www-cigna-com/docs/medicare/plans-services/2021/step-therapy-secure-essential.pdf
[26] tel:1-877-813-5595
[27] https://www.cigna.com/static/www-cigna-com/docs/medicare/plans-services/2021/pdp-redetermination.pdf
[28] tel:1-866-845-6962
[29] tel:1-800-997-1654
[30] https://www.elixirpartd.com/hubfs/ElixirInsurance/docs/Formulary/EIC_Middle_Enhanced_RxPlus_CY2021_Marketing_Comprehensive_ENG_010121.pdf
[31] https://www.elixirpartd.com/hubfs/ElixirInsurance/docs/Formulary/EIC_Benchmark_RxSecure_CY2021_Marketing_Comprehensive_ENG_010121.pdf
[32] https://www.elixirpartd.com/hubfs/ElixirInsurance/docs/Determination_Form_pf1.pdf
[33] https://www.elixirpartd.com/hubfs/ElixirInsurance/docs/Formulary/EIC_Middle_Enhanced_RxPlus_CY2021_Marketing_PA_010121.pdf
[34] https://www.elixirpartd.com/hubfs/ElixirInsurance/docs/Formulary/EIC_Middle_Enhanced_RxPlus_CY2021_Marketing_ST_010121.pdf
[35] https://www.elixirpartd.com/hubfs/ElixirInsurance/docs/Formulary/EIC_Middle_Enhanced_RxPlus_CY2021_Marketing_QL_010121.pdf
[36] https://www.elixirpartd.com/hubfs/ElixirInsurance/docs/Formulary/EIC_Benchmark_RxSecure_CY2021_Marketing_PA_010121.pdf
[37] https://www.elixirpartd.com/hubfs/ElixirInsurance/docs/Formulary/EIC_Benchmark_RxSecure_CY2021_Marketing_ST_010121.pdf
[38] https://www.elixirpartd.com/hubfs/ElixirInsurance/docs/Formulary/EIC_Benchmark_RxSecure_CY2021_Marketing_QL_010121.pdf
[39] tel:1-866-250-2005
[40] https://www.elixirpartd.com/hubfs/ElixirInsurance/docs/Redetermination_Form_pf1.pdf
[41] https://www.express-scriptsmedicare.com/part-d.shtml
[42] https://www.express-scriptsmedicare.com/pdf/medicare/medicare-part-d-2021-formulary-value.pdf
[43] https://www.express-scriptsmedicare.com/pdf/medicare/medicare-part-d-2021-formulary-choice.pdf
[44] https://www.express-scriptsmedicare.com/pdf/medicare/medicare-part-d-2021-formulary-saver.pdf
[45] https://www.express-scriptsmedicare.com/pdf/medicare/medicare-part-d-2021-coverage-review-fax-form.pdf
[46] https://www.express-scriptsmedicare.com/pdf/medicare/medicare-part-d-2021-prior-authorization-value.pdf
[47] https://www.express-scriptsmedicare.com/pdf/medicare/medicare-part-d-2021-step-therapy-value.pdf
[48] https://www.express-scriptsmedicare.com/pdf/medicare/medicare-part-d-2021-prior-authorization-choice.pdf
[49] https://www.express-scriptsmedicare.com/pdf/medicare/medicare-part-d-2021-step-therapy-choice.pdf
[50] https://www.express-scriptsmedicare.com/pdf/medicare/medicare-part-d-2021-prior-authorization-saver.pdf
[51] https://www.express-scriptsmedicare.com/pdf/medicare/medicare-part-d-2021-step-therapy-saver.pdf
[52] tel:1-844-374-7377
[53] tel:1-800-716-3231
[54] https://www.express-scriptsmedicare.com/pdf/medicare/medicare-part-d-2021-redetermination-fax-form.pdf
[55] tel:1-866-477-5703
[56] https://www.humana.com/
[57] https://docushare-web.apps.cf.humana.com/Marketing/docushare-app?file=4085081
[58] https://docushare-web.apps.cf.humana.com/Marketing/docushare-app?file=4085367
[59] https://docushare-web.apps.cf.humana.com/Marketing/docushare-app?file=4085263
[60] https://docushare-web.apps.cf.humana.com/Marketing/docushare-app?file=1828827
[61] https://docushare-web.apps.cf.humana.com/Marketing/docushare-app?file=4134468
[62] https://docushare-web.apps.cf.humana.com/Marketing/docushare-app?file=4134481
[63] https://docushare-web.apps.cf.humana.com/Marketing/docushare-app?file=4134598
[64] https://docushare-web.apps.cf.humana.com/Marketing/docushare-app?file=4134611
[65] https://docushare-web.apps.cf.humana.com/Marketing/docushare-app?file=4134754
[66] https://docushare-web.apps.cf.humana.com/Marketing/docushare-app?file=4134767
[67] tel:1-800-555-2546
[68] https://docushare-web.apps.cf.humana.com/Marketing/docushare-app?file=1612286
[69] tel:1-877-320-1235
[70] tel:1-800-457-4708
[71] https://www.mutualofomaha.com/prescription-drug-plan/our-plans
[72] http://cdn.mutualofomaha.com/documents/mutualofomaha/pdf/prescription-drug-plans/druglist-plus.pdf?_ga=2.184127078.1561709305.1603804268-594924176.1603804268
[73] http://cdn.mutualofomaha.com/documents/mutualofomaha/pdf/prescription-drug-plans/druglist-premier.pdf?_ga=2.117473993.1561709305.1603804268-594924176.1603804268
[74] https://cdn.mutualofomaha.com/documents/mutualofomaha/pdf/prescription-drug-plans/coverage-determination-form.pdf?_ga=2.184102630.1561709305.1603804268-594924176.1603804268
[75] https://cdn.mutualofomaha.com/documents/mutualofomaha/pdf/prescription-drug-plans/prior-authorization-plus.pdf?_ga=2.88695387.1561709305.1603804268-594924176.1603804268
[76] https://cdn.mutualofomaha.com/documents/mutualofomaha/pdf/prescription-drug-plans/step-therapy-plus.pdf?_ga=2.88121947.1561709305.1603804268-594924176.1603804268
[77] https://cdn.mutualofomaha.com/documents/mutualofomaha/pdf/prescription-drug-plans/prior-authorization-premier.pdf?_ga=2.88695387.1561709305.1603804268-594924176.1603804268
[78] https://cdn.mutualofomaha.com/documents/mutualofomaha/pdf/prescription-drug-plans/step-therapy-premier.pdf?_ga=2.88121947.1561709305.1603804268-594924176.1603804268
[79] tel:1-800-935-6103
[80] https://cdn.mutualofomaha.com/documents/mutualofomaha/pdf/prescription-drug-plans/coverage-redetermination-form.pdf?_ga=2.112233796.1561709305.1603804268-594924176.1603804268
[81] tel:1-855-864-6797
[82] https://www.aetnamedicare.com/
[83] https://www.aetnamedicare.com/documents/individual/2021/formularies/FORM_2021_CHOICE_EN.pdf
[84] https://www.aetnamedicare.com/documents/individual/2021/formularies/FORM_2021_PLUS_EN.pdf
[85] https://www.aetnamedicare.com/documents/individual/2021/formularies/FORM_2021_SMARTRX_EN.pdf
[86] https://www.aetnamedicare.com/documents/individual/website/appeals/part_d_cov_determ_form.pdf
[87] https://www.aetnamedicare.com/documents/individual/2021/formularies/PA_2021_CHOICE.pdf
[88] https://www.aetnamedicare.com/documents/individual/2021/formularies/ST_2021_CHOICE.pdf
[89] https://www.aetnamedicare.com/documents/individual/2021/formularies/PA_2021_PLUS.pdf
[90] https://www.aetnamedicare.com/documents/individual/2021/formularies/ST_2021_PLUS.pdf
[91] https://www.aetnamedicare.com/documents/individual/2021/formularies/PA_2021_SMARTRX.pdf
[92] https://www.aetnamedicare.com/documents/individual/2021/formularies/ST_2021_SMARTRX.pdf
[93] tel:1-800-414-2386
[94] https://www.aetnamedicare.com/documents/individual/website/appeals/redetermination-and-appeal-form.pdf
[95] tel:1-866-235-5660
[96] tel:1-855-335-1407
[97] https://www.aarpmedicareplans.com/
[98] https://www.aarpmedicareplans.com/alphadms/ovdms10g/groups/ov/@ov/@highrespdf/documents/highrespdf/4852599.pdf
[99] https://www.aarpmedicareplans.com/alphadms/ovdms10g/groups/ov/@ov/@highrespdf/documents/highrespdf/4949407.pdf
[100] https://www.aarpmedicareplans.com/alphadms/ovdms10g/groups/ov/@ov/@highrespdf/documents/highrespdf/4852606.pdf
[101] https://www.aarpmedicareplans.com/online_documents/ovation/pdf/pdp/en/2021/Prior_Auth_PPREFP_2021.pdf
[102] https://www.aarpmedicareplans.com/online_documents/ovation/pdf/pdp/en/2021/Step_Therapy_PPREFP_2021.pdf
[103] https://www.aarpmedicareplans.com/online_documents/ovation/pdf/pdp/en/2021/Prior_Auth_PSAVE_2021.pdf
[104] https://www.aarpmedicareplans.com/online_documents/ovation/pdf/pdp/en/2021/Step_Therapy_PSAVE_2021.pdf
[105] https://www.aarpmedicareplans.com/online_documents/ovation/pdf/pdp/en/2021/Prior_Auth_PWAG_2021.pdf
[106] https://www.aarpmedicareplans.com/online_documents/ovation/pdf/pdp/en/2021/Step_Therapy_PWAG_2021.pdf
[107] https://www.aarpmedicareplans.com/content/dam/shared/documents/Medicare_PartD_Coverage_Determination_Request_Form.pdf
[108] tel:1-800-711-4555
[109] https://www.aarpmedicareplans.com/content/dam/shared/documents/Redetermination_Request_Form.pdf
[110] tel:1-800-595-9532
[111] tel:1-800-556-7596
[112] https://mainelse.org/content/Part_D/formulary-links-forms-and-contacts#top
[113] https://contentserver.destinationrx.com/ContentServer/DRxProductContent/PDFs/149_0/NA1PDGFOR57128E_CV07.pdf
[114] https://contentserver.destinationrx.com/ContentServer/DRxProductContent/PDFs/149_0/NA1PDAFOR57122E_CV04.pdf
[115] https://contentserver.destinationrx.com/ContentServer/DRxProductContent/PDFs/149_0/NA1PDCFOR57124E_CV05.pdf
[116] https://contentserver.destinationrx.com/ContentServer/DRxProductContent/PDFs/149_0/NA1PDGFOR57126E_CV06.pdf
[117] https://www.wellcare.com/Maine/Forms/Request-PDP-Prescription-Drug-Coverage
[118] tel:1-888-550-5252
[119] https://www.wellcare.com/Maine/Forms/Request-Appeal-for-PDP-Drug-Coverage
[120] tel:1-855-797-4357
[121] http://mainecarepdl.org/pdl
[122] http://mainecarepdl.org/pafiles
[123] https://www.cms.gov/Medicare/Appeals-and-Grievances/MedPrescriptDrugApplGriev/CoverageDeterminationsandExceptions.html
[124] https://mlsed7.n2c.us/sites/default/files/Model%20Coverage%20Determination%20Request%20Form_Jan2019v508.pdf