Formulary Links, Forms and Contacts

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Aetna (Aetna-Medicare Rx Saver Plan)

Aetna Website

Aetna Saver Formulary (Drug List)

Drug Search Tool - Click on "For 2017" then click "Search for Your Prescription Drug"

Coverage Determination Form

Prior Authorization Criteria, Step Therapy Requirements - Click on "Prior Authorization Information" or "Step Therapy Information"

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

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

Redetermination (First Level Appeal) Form

Redetermination Appeal Fax: 860-907-3984

Expedited Redetermination Appeal Phone: 1-877-235-3755

Customer Service Phone (Members): 1-877-238-6211 / TTY: 711 

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Anthem (Blue Standard, Blue Premier, Blue Plus Plans)

Anthem Website

Formularies (drug lists):

Blue Medicare Rx Standard

Blue Medicare Rx Premier

Blue Medicare Rx Plus

Coverage Determination Form (handled by Express Scripts)

Coverage Determination (Prior Authorization) Phone: 1-800-338-6180 (TTY: 1-800-899-2114)

Coverage Determination (Prior Authorization) Fax: 1-877-526-2307

Redetermination (First Level Appeal) Form

Expedited Redetermination (First Level) Appeals can be done by phone: 1-866-755-2776 (TTY: 711)

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

Customer Service Line (also for doctors, pharmacists etc, different options): 1-866-755-2776

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Cigna-Healthspring Rx (Cigna-Healthspring Secure, Cigna-Healthspring Secure-Xtra)

Cigna-Healthspring Website

Formularies (drug lists):

Cigna-Healthspring Secure Plan Formulary

Cigna-Healthspring Secure-Xtra Plan Formulary

Criteria for Drugs with Quantity Limits, Step Therapy, or Prior Authorizations restrictions
Under "2017 Medicare Part D", go to "Quantity Limit Criteria", "Step Therapy Criteria" or "Prior Authorization Criteria", then click on the name of your plan.

Coverage Determination (Prior Authorization) Form

PA forms for certain specific medications
Click on Prior Authorization Forms, then in box, scroll down and click on your drug

Coverage Determination (Prior Authorization) Phone: 1-800-222-6700

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

Redetermination (First Level Appeal) Form

Expedited Redetermination Appeal Phone: 1-800-222-6700

Redetermination Appeal  Fax: 1-866-593-4482

Customer Service: 1-800-735-1459 or 1-800-222-6700

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Envision (EnvisionRx Plus Plan)

EnvisionRx Plus Website

Envision Rx Plus Formulary (drug list)

Coverage Determination (Prior Authorization) Form

Prior Authorization Forms for Certain Specific Drugs
Scroll down to Envision RxPlus Prior Authorizations, click on Maine in the box, then scroll down to Prior Authorization and Coverage Determination Forms and click on your medication

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

Coverage Determination (Prior Authorization), Appeals and Grievance Fax: 1-877-503-7231

Redeterimination (First Level Appeal) Form

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

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

Customer Service Phone: 1-866-250-2005 (TTY/TDD 711)

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Express Scripts Medco (Choice and Value Plans)

Express Scripts/Medco Website

Formularies (drug lists):

Value Plan
Under Medicare Part D Formulary, click on "View Value plan drug list"

Choice Plan
Under Medicare Part D Formulary, click on "View Choice plan drug list"

Coverage Determination Form

Criteria for Prior Authorizations and Step Therapy Exceptions
Go to Value Plan or Choice Plan and click on Prior Authorization or Step Therapy criteria

Coverage Determination (Prior Authorization) Phone: 1-800-935-6103 (TTY/TDD 1-800-716-3231)

Coverage Determination (Prior Authorization) Fax: 1-877-328-9799

Redetermination (First Level Appeal) Form

Redetermination Appeal Phone (Expedited Appeals): 1-800-935-6103 (TTY 1-800-716-3231)

Redetermination Appeal Fax: 1-877-852-4070

Customer Service: 1-800-758-4574 or 1-866-477-5703

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First Health (Premier Plus, Value Plus Plans)

First Health Premier Website

Formularies (Drug Lists)

Premier Plus

Value Plus

Coverage Determination Form

Expedited Coverage Determinations (Prior Authorizations) Phone: 1-800-551-2694 (TTY 711)

Coverage Determinations (Prior Authorizations) Fax: 1-800-639-9158

Redetermination (First Level Appeal) Form

Expedited Redetermination Appeal Phone: 1-800-536-6167

Redetermination Appeal Fax: 1-800-535-4047

Customer Service Phone: 1-844-233-1938

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Humana (Humana-Walmart, Humana Preferred Rx, Humana Enhanced Plans)

Humana Website

Formularies (Drug Lists):

Humana-Walmart Plan

Humana-Preferred Plan

Humana Enhanced Plan

Coverage Determination Form

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

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

Customer Service: 1-800-706-0872 (TTY: 711)

Customer Service (Members): 1-800-281-6918

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Magellan (Basic Plan)

Magellan Website

Basic Plan Formulary (Drug List)

Criteria for Drugs requiring a Prior Authorization of having step therapy restrictions
Scroll down page. Near the bottom click on Drugs subject to Prior Authorization, or Drugs subject to Step Therapy. Then go to drug at issue.

Coverage Determination Form (and other forms)
Scroll down to Coverage Determinations, then click on Coverage Determination form

Coverage Determination Phone: 1-800-424-5870

Coverage Determination Fax: 1-800-424-5872

Customer Service Phone: 1-800-424-5870 (TTY: 711)

Redetermination (First Level Appeal) Form|
Under “What is an appeal?” click on "Redetermination Request Form"

Expedited Redetermination Appeal Phone: 1-800-424-5870

Redetermination Appeal Fax: 1-800-424-5872

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Silverscript (Choice and Plus Plans)

Silverscript Website

Formularies (Drug Lists):

Silverscript Choice Plan

Silverscript Plus Plan

Coverage Determination Form

Coverage Determination (Prior Authorization) Phone: 1-866-235-5660 (TTY: 711)

Coverage Determination (Prior Authorization) Fax: 1-855-633-7673

Redetermination (First level Appeal) Form

Redetermination (First level Appeal) Fax: 1-855-633-7673

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

Customer Service: 1-866-362-6212 (TTY: 1-866-552-6288)

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Symphonix (Value Plan)

Symphonix Health Website

Formulary (Drug List):

Symphonix RX Value Plan

Criteria for Prior Authorizations, Step therapy, changes to Formulary, etc.
Scroll down to Plan Documents, then click on information you want  

Coverage Determination (Prior Authorization) Form

Coverage Determination (Prior Authorization) (Optum Rx) Phone: 1-888-326-1004 (TTY: 711)

Coverage Determination (Prior Authorization) Fax: 1-800-527-0531

Customer Service for Claims and Benefits Phone: 1-888-326-1004

For Premiums, Complaints, or General Issues Phone: 1-855-355-2280

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

AARP Medicare Plans Website

Formularies (Drug Lists):

AARP Saver Plus

AARP Preferred

AARP Walgreens

Coverage Determination Form

Coverage Determination (Prior Authorization) Phone (Optum Rx): 1-800-711-4555

Coverage Determination (Prior Authorization) Fax: 1-800-527-0531, Fax for Specialty Drugs 1-800-853-3844

Customer Service Phone: 1-866-255-4835

Customer Service Phone (Members): 1-888-867-5575

Redetermination (First Level Appeal) Form

Redetermination Appeal Fax: 1-800-595-9532

Expedited Redetermination Appeals can be done by phone: 1-800-595-9532

Customer Service Phones: 1-866-255-4835, 1-888-867-5575, 1-877-710-5083

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WellCare (Classic and Extra Plans)

WellCare Website

Formularies (Drug Lists):

Wellcare Drug Search Tool - Put in the name of your medication and click Search

WellCare Classic Plan - Click on Comprehensive Formulary

WellCare Extra Plan - Scroll down and click on Comprehensive Formulary

Coverage Determination Form

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

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

Redetermination (First Level Appeal) Form

Redetermination Fax: 1-866-388-1766

Expedited Redetermination Phone: 1-888-550-5252

Customer Service Phone: 1-800-264-1587 (TTY/TTD: 1-888-816-5252)

General Phone: 1-800-960-2530 (TTY: 1-877-247-6272)

Pharmacy Provider Phone: 1-855-538-0453 (Option 2 for Pharmacy Provider)

 

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MaineCare Member Services: 1-800-977-6740

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

The CMS website has a standard form for coverage determinations (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 December 2016