Formulary Links, Forms and Contacts

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Aetna (Aetna-CVS/Pharmacy Drug Plan)

Aetna Website

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 Medicare Rx (Cigna Secure, Cigna Secure-Xtra, Cigna Secure-Max Plans)

Cigna Website

Cigna Formularies:

Cigna Secure Plan

Cigna Secure-Xtra Plan

Cigna Secure-Max Plan

Coverage Determination (Prior Authorization) Form

Other Forms

Coverage Determination (Prior Authorization) Phone: 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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Cigna/Healthspring Plan (NEW)

Cigna-Healthspring Website

Formulary

Coverage Determination (Prior Authorization) Form
Click on specific drug you are taking. If drug not listed, click on General Form

Coverage Determination (PA) Phone (for General Coverage Determinations): 1-877-813-5595, for specific drugs with special Coverage Determination form, use phone number on form

Coverage Determination (PA) Fax: 1-866-845-7267

Customer Service (Members) Phone: 1-800-331-6293 (TTY/TDD 711)

Customer Service (Prospective Members) Phone: 1-877-357-1685

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EnvisionRx Plus (Silver Plan)

EnvisionRx Plus Website

Formulary

Coverage Determination (Prior Authorization) Form

Prior Authorization Forms for Certain Specific Drugs

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 Medicare (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

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

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First Health (Essentials, Premier Plus, Value Plus Plans)

First Health Premier Website

Formularies
Find your 2014 Plan and click on “Printable Comprehensive Formulary” or click on “Online Search Tool”

Coverage Determination Form

Coverage Determination (Prior Authorization) Phone: 1-800-551-2694 (TTY/TDD 711)

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

Customer Service Phone: 1-800-588-3322

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

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HealthMarkets (Value Plan)

HealthMarkets Value Plan Website

Formulary

Coverage Determination (Prior Authorization) Form

Coverage Determination (Prior Authorization) Phone: 1-888-630-9137

Coverage Determination (Prior Authorization) Fax: 1-866-391-0162

Customer Service: 1-888-625-5531 (TTY/TTD 711)

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

Humana Website

Formularies:

Humana-Walmart Plan

Humana-Preferred Plan

Humana Enhanced Plan

Forms:
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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Symphonix Rite-Aid Value Plan

Symphonix Rite-Aid Value Website

Formulary
Then click on "2014 Comprehensive Formulary"

Coverage Determination (Prior Authorization) Form
Then click on "Prior Authorization Form" on the left hand side

Coverage Determination (Prior Authorization) 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:

Classic Plan Form

Choice Plan Form

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 (Select Plan)

Website Link

Formulary

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, AARP Preferred, AARP Enhanced Plans)

AARP Medicare Rx Plan Website

Comprehensive Formularies:

AARP Saver Plus

AARP Preferred

AARP Enhanced

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

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 January 2014