Formulary Links, Forms and Contacts

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Aetna (Aetna-Medicare Rx Saver Plan)

Aetna Website

Aetna Saver Formulary

Drug Search Tool

Coverage Determination Form

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

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

Redetermination (1st Level Appeal) Form

Redetermination Appeal Fax: 860-907-3084

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

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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, for TTY users 1-800-899-2114

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

Redetermination (1st Level Appeal) Form

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

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
Click on the category (Step therapy, Prior Authorization, Quantity Limit etc.) and the name of your Plan

Coverage Determination (Prior Authorization) Form
Click on "Prior Authorization Forms for Physicians" then click on the form you need.

PA forms for certain specific medications
Click on Prior Authorization forms, scroll down to your drug

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

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

Redetermination (1st Level Appeal) Form

Redetermination Appeal Phone: 1-800-222-6700

Redetermination Appeal  Fax: 1-866-593-4482

Other Forms
Click on "Prescription Drug (Part D) Forms," then click on the form you need.

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

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EnvisionRx Plus (Silver and Clear Choice Plans)

EnvisionRx Plus Website

Formularies (drug lists)

Silver Plan Formulary
Under 2016 Envision Rx Plus Silver Benefit Plan click on "Download Comprehensive Formulary"

Clear Choice Plan Formulary
Under 2016 Envision Rx Clear Choice Benefit Plan click on “DownloadComprehensive Formulary”

Coverage Determination (Prior Authorization) Form

Prior Authorization Forms for Certain Specific Drugs
Scroll down to "EnvisionRx Plus Prior Authorization - Choose Your State", Select "Maine", click on drug needed

Appeals and Grievance Information and Drug-specific Forms

Redeterimination (1st Level Appeal) Form

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

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

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:

Value Plan

Choice Plan

Coverage Determination Form

Criteria for Prior Authorizations and Step Therapy Exceptions

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 (1st 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 and on-line drug search tool
Find your 2016 Plan and click on “Printable Comprehensive Formulary” or click on “Online Search Tool”

Coverage Determination Form

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

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

Redetermination (1st Level Appeal) Form

Redetermination Appeal Phone: 1-800-536-6167

Redetermination Appeal Fax: 1-800-535-4047

Customer Service Phone: 1-877-988-3589

Customer Service (Members) Phone: 1-866-865-0662

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

Humana Website

Formularies:

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

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

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Magellan (Basic Plan)

Magellan Website

Basic Plan Formulary

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 (1st Level Appeal) Form|
Under “What is an appeal?” click on "Redetermination Request Form"

Redetermination Appeal Phone: 1-800-424-5870

Redetermination Appeal Fax: 1-800-424-5872


Silverscript (Choice and Plus Plans)

Silverscript Website

Formularies:

Silverscript Choice Plan

Silverscript Plus Plan

Coverage Determination Form

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

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

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Symphonix Rite-Aid (Value and Prime Saver Plans)

Symphonix Health Website

Formularies:

Symphonix RX Value Plan
On dropdown menu, click on Maine, then click on "2016 Symphonix Value Rx Comprehensive Formulary"

Symphonix PrimeSaver
On dropdown menu click on Maine, then click on "2016 Symphonix PrimeSaver Rx Comprehensive Formulary"

Coverage Determination (Prior Authorization) Form
Scroll down main text, then click on Prescription Drug Determination 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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Transamerica Medicare Rx (Classic and Choice Plans)

Transamerica Website

Formularies

Transamerica Classic Plan

Coverage Determination Online Request Form

Coverage Determination Form for Prescribers

Coverage Determination (Prior Authorization) Phone: 1-888-672-7206

Coverage Determination (Prior Authorization) Fax: 1-858-790-7100

Customer Service Phone: 1-877-527-1958

Customer Service (Members) Phone: 1-888-672-7206

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United Healthcare (AARP Saver and AARP Preferred Plans)

AARP Medicare Rx Plan Website

Comprehensive Formularies:

AARP Saver Plus

AARP Preferred

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

SPAP members (SPAP means Maine residents with Medicare and full MaineCare, the Buy In, and/or the Drugs for the Elderly program): 1-877-710-5083

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WellCare (Classic and Extra Plans)

WellCare Website

Formularies:

WellCare Classic Plan Formulary
Scroll down to "Comprehensive Formulary", then click on "Download WellCare Classic Plan"

Wellcare Classic Drug Search Tool

WellCare Extra Plan Formulary

Wellcare Extra Plan Drug Search Tool

Coverage Determination Form

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

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

Redetermination (1st Level Appeal) Form

Redetermination Fax: 1-866-388-1766

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

Provider Phone: 1-855-538-0453 (Option 2 for medical provider, Option 3 for Pharmacist)

 

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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) under Medicare Part D, together with instructions for completing the form. This form can be used with any Medicare Part D Plan.

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Updated January 2016