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 2018” 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: 724-741-4954

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

Prior Authorization Criteria, Step Therapy Requirements:

Blue Medicare Rx Standard: Prior Authorization Requirements and Step Therapy Requirements

Blue Medicare Rx Premier: Prior Authorization Requirements and Step Therapy Requirements

Blue Medicare Rx Plus: Prior Authorization Requirements and Step Therapy Requirements

Coverage Determination Form (handled by Express Scripts)

Coverage Determination (Prior Authorization) Phone: 1-866-755-2776

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: 1-888-458-1406

Customer Service Line (Members): 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

Drug Search Tool

Coverage Determination (Prior Authorization) Form

Prior Authorization and Step Therapy Requirements

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 (Members): 1-855-391-2556 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 and Step Therapy Requirements

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

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

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Express Scripts Medicare (Value, Choice, Saver Plans)

Express Scripts Website

Formularies (drug lists):

Value Plan

Choice Plan

Saver Plan

Coverage Determination Form

Criteria for Prior Authorizations and Step Therapy Exceptions

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

Coverage Determination (Prior Authorization) Fax: 1-877-328-9660

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 Phone (Members): 1-866-477-5703 (TTY 1-800-716-3231)

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First Health (Value Plus, Premier Plus Plans)

First Health Website

Formularies (Drug Lists):

Value Plus

Premier 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: 1-877-235-3755 (TTY 711)

Redetermination Appeal Fax: 724-741-4954

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 Phone: 1-800-457-4708 (TTY 711)

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Magellan (Basic Plan)

Magellan Website

Basic Plan Formulary (Drug List)

Prior Authorization and Step Therapy Requirements

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

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

Redetermination Appeal Fax: 1-800-424-5872

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

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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 Phone: 1-866-362-6212 (TTY: 1-866-552-6288)

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

United Healthcare Website

Formularies (Drug Lists):

AARP Preferred

AARP Saver Plus

AARP Walgreens

Symphonix Value

Coverage Determination Form

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

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

Redetermination (First Level Appeal) Form

Redetermination Appeal Fax: 1-866-308-6294

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

Customer Service Phone: 1-877-596-3258

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WellCare (Classic and Extra Plans)

WellCare Website

Formularies (Drug Lists):

WellCare Classic

WellCare Extra

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: 1-888-550-5252 (TTY/TTD: 1-888-816-5252)

General Phone: 1-866-537-1812 (TTY: 1-888-816-5252)

Pharmacy Provider Phone: 1-888-550-5252

 

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MaineCare Member Services: 1-855-797-4357

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 2017