Formulary Links, Forms and Contacts

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Aetna (Rx Saver, Rx Value Plus, Rx Select Plans)

Aetna Website

Formularies (drug lists):

Rx Saver

Rx Value Plus

Rx Select

Drug Search Tool: Click on “For 2019” then click “Search for Your Prescription Drug”

Coverage Determination Form

Prior Authorization Criteria, Step Therapy Requirements:

Rx Saver: Prior Authorization Requirements and Step Therapy Requirements

Rx Value Plus: Prior Authorization Requirements and Step Therapy Requirements

Rx Select: Prior Authorization Requirements and Step Therapy Requirements

Coverage Determination (Prior Authorization) Phone:

Rx Saver: 1-800-414-2386

Rx Value Plus: 1-800-245-1206 / TTY: 711

Rx Select: 1-800-414-2386

Coverage Determination (Prior Authorization) Fax:

Rx Saver: 1-800-408-2386

Rx Value Plus: 1-859-455-8650

Rx Select: 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): 1-888-247-1051 / TTY: 711 

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Anthem (Blue Standard, Blue Plus Plans)

Anthem Website

Formularies (drug lists):

Blue Medicare Rx Standard

Blue Medicare Rx Plus

Prior Authorization Criteria, Step Therapy Requirements:

Blue Medicare Rx Standard: 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: 1-833-293-0661

Coverage Determination (Prior Authorization) Fax: 1-844-521-6938

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 Secure-Essential)

Cigna-Healthspring Website

Formularies (drug lists):

Cigna-Healthspring Secure Plan Formulary

Cigna-Healthspring Secure-Xtra Plan Formulary

Cigna-Healthspring Secure-Essential Plan Formulary

Coverage Determination (Prior Authorization) Form

Drug Search Tool

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 Criteria, Step Therapy Requirements, and Quantity Limits Criteria

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

Coverage Determination (Prior Authorization) Fax: 1-877-503-7231

Redetermination (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: 1-877-251-5896 or 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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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

Criteria for Prior Authorizations

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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Mutual of Omaha (Rx Plus, Rx Value Plans)

Mutual of Omaha Website

Formularies (Drug Lists):

Rx Plus

Rx Value

Coverage Determination Form

Prior Authorization and Step Therapy Requirements

Rx Plus: Prior Authorization Criteria and Step Therapy Requirements

Rx Value: Prior Authorization Criteria and Step Therapy Requirements

Coverage Determination (Prior Authorization) Phone: 1-800-935-6103

Coverage Determination (Prior Authorization) Fax: 1-877-251-5896

Redetermination (First Level Appeal) Form

Redetermination Appeal Fax: 1-877-852-4070

Expedited Redetermination Appeals can be done by phone: 1-800-935-6103 (TTY: 1-800-716-3231

Customer Service Phone: 1-800-961-9006 (TTY: 1-800-584-6939

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Silverscript (Choice, Plus, Allure Plans)

Silverscript Website

Formularies (Drug Lists):

Silverscript Choice Plan

Silverscript Plus Plan

Silverscript Allure Plan

Coverage Determination Form

Criteria for Step Therapy

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: 711)

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

United Healthcare Website

Formularies (Drug Lists):

AARP Preferred

AARP Saver Plus

AARP Walgreens

Coverage Determination Form

Prior Authorization Criteria and Step Therapy Requirements

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, Extra, Value Script Plans)

WellCare Website

Formularies (Drug Lists):

WellCare Classic

WellCare Extra

WellCare Value Script

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 (First Level Appeal) Form

Redetermination Fax: 1-866-388-1766

Expedited Redetermination Phone: 1-888-550-5252

Customer Service Phone: 1-877-818-8744 (TTY: 1-888-816-5252)

General Phone: 1-866-537-1812 or 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 November 2018