Formulary Links, Forms and Contacts

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Aetna (Aetna-Medicare Rx Saver Plan)

Aetna Website

Aetna Saver Formulary

Drug Search Tool & Criteria for Drug Coverage

Coverage Determination Form

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

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

Customer Service Phone: 1-800-529-5586 or 1-888-247-1051

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

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

Anthem Website

Formularies:

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

Expedited Redetermination (1st level Appeal) requests can be done by phone: 1-866-755-2776

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 Secure-Max Plans)

Cigna-Healthspring Website

Cigna-Healthspring Formularies:

Cigna-Healthspring Secure Plan

Cigna-Healthspring Secure-Max Plan

Cigna-Healthspring Secure-Xtra Plan

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

Other Forms
 

Click on "Prescription Drug Plan Forms," then click on the form you need.

Coverage Determination (Prior Authorization) Phone for Prescribers: 1-800-558-9363

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

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

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EnvisionRx Plus (Silver Plan)

EnvisionRx Plus Website

Silver Plan Formulary
In the box on the right, Select Maine. Then on the next page, click on "Download Comprehensive 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

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

Coverage Determination (Prior Authorization) Fax: 1-877-329-3760

Redetermination (1st Level Appeal) Form

Redetermination 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
Find your 2015 Plan and click on “Printable Comprehensive Formulary” or click on “Online Search Tool”

Coverage Determination Form

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

Customer Service Phone: 1-800-551-2694

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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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 Premier Plans)

Symphonix Health Website

Formularies:

Rite-Aid Value Plan
Enter your state (Maine), then click on "2015 Bronze Formulary" (Value Formulary comes up)

Rite-Aid Premier Plan
Enter your state (Maine), then click on "2015 Premier Formulary"
 

Coverage Determination (Prior Authorization) Form
Then click on "Prior Authorization Form"

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

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

Customer Service Phone:
For Premiums, Complaints, or General Issues: 1-855-355-2280
For Claims and Benefits: 1-888-326-1004

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Transamerica Medicare Rx (Classic and Choice Plans)

Transamerica Website

Formularies

Transamerica Classic Plan

Transamerica Choice Plan

Coverage Determination (Prior Authorization) Forms

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 American: UA (Essential and Select Plans)

Website Link

Formularies:

Essential Plan

Select Plan

Coverage Determination Form

Coverage Determination (Prior Authorization) Phone (Express Scripts): 1-800-753-2851 (TTY/TTD 1-800-716-3231)

Coverage Determination (Prior Authorization) Fax (Express Scripts): 1-888-235-8551

Customer Service: 1-866-524-4169

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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

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

WellCare Extra Plan

Coverage Determination Form

Coverage Determination (Prior Authorization) Phone: 1-866-800-6111 (TTY/TDD 1-888-816-5252)For Members: Choose Option 1
For Pharmacists: Choose Option 2
For Physicians or Staff: Choose Option 3

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

First Level Appeal (Redetermination) Form

First Level Appeal (Redetermination) Fax: 1-866-388-1766

Various Other Forms

Customer Service Phone: 1-866-765-4390 

Customer Service Phone (Members): 1-888-550-5252 (TTY/TTD 1-888-816-5252)

 

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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 December 2014