Formulary Links, Forms and Contacts

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Anthem (MediBlue Enhanced, MediBlue Rx Plus, MediBlue Rx Standard)

Anthem Website

Formularies (drug lists):

MediBlue Enhanced

MediBlue Rx Plus

MediBlue Rx Standard

Prior Authorization Criteria, Step Therapy Requirements:

MediBlue Enhanced: Prior Authorization Criteria and Step Therapy Requirements

MediBlue Rx Plus: Prior Authorization Criteria and Step Therapy Requirements

MediBlue Rx Standard: Prior Authorization Criteria and Step Therapy Requirements

Coverage Determination Form

Coverage Determination (Prior Authorization) Phone: 1-833-293-0661  (TTY 711)

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

Redetermination (First Level Appeal) Form

Redetermination (First Level Appeal) Phone:  1-866-755-2776  (TTY 711)

Redetermination (First Level Appeal) Fax: 1-888-458-1407

Expedited Redetermination (First Level Appeal) Phone:  1-866-755-2776  (TTY 711)

Customer Service Line (Members): 1-866-755-2776  (TTY 711)

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Cigna-Healthspring Rx (Secure Rx, Secure-Extra Rx, Secure-Essential Rx)

Cigna-Healthspring Website

Formularies (drug lists):

Secure Rx Plan

Secure-Extra Rx Plan

Secure-Essential Rx Plan

Coverage Determination (Prior Authorization) Form

Prior Authorization Criteria, Step Therapy Requirements

Secure Rx:  Prior Authorization Criteria and Step Therapy Requirements

Secure-Extra Rx:  Prior Authorization Criteria and Step Therapy Requirements

Secure-Essential Rx:  Prior Authorization Criteria and Step Therapy Requirements

Coverage Determination (Prior Authorization) Phone: 1-877-813-5595

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

Redetermination (First Level Appeal) Form

Redetermination Appeal Phone:  1-866-845-6962

Redetermination Appeal Fax: 1-866-593-4482

Expedited Redetermination Appeal Phone: 1-866-845-6962

Customer Service (Members): 1-800-997-1654 (TTY/TDD 711)

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Elixir (Rx Plus, Rx Secure Plans)

Elixir Website

Formularies (drug lists):

Elixir Rx Plus

Elixir Rx Secure

Coverage Determination (Prior Authorization) Form

Elixir Rx Plus:  Prior Authorization Criteria, Step Therapy Requirements, and Quantity Limits Criteria

Elixir Rx Secure:  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

Prior Authorization Criteria, Step Therapy Requirements

Value Plan:  Prior Authorization Criteria and Step Therapy Requirements

Choice Plan:  Prior Authorization Criteria and Step Therapy Requirements

Saver Plan:  Prior Authorization Criteria and Step Therapy Requirements

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

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

Redetermination (First Level Appeal) Form

Redetermination Appeal Phone: 1-844-374-7377 (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 (Basic, Premier, Walmart Value Plans)

Humana Website

Formularies (Drug Lists):

Basic Plan

Premier Plan

Walmart Value Plan

Coverage Determination Form

Prior Authorization Criteria, Step Therapy Requirements

Basic Plan:  Prior Authorization Criteria and Step Therapy Requirements

Premier Plan:  Prior Authorization Criteria and Step Therapy Requirements

Walmart Value Plan:  Prior Authorization Criteria and Step Therapy Requirements

Coverage Determination (Prior Authorization) Phone: 1-800-555-2546

Coverage Determination (Prior Authorization) Fax: 1-877-486-2621

Redetermination (First Level Appeal) Form

Redetermination Appeal Phone:  1-877-320-1235

Redetermination Appeal Fax:  1-888-556-2128

Expedited Redetermination Appeal Phone:  1-877-320-1235

Expedited Redetermination Appeal Fax:  1-888-556-2128

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 Premier

Coverage Determination Form

Prior Authorization Criteria, Step Therapy Requirements

Rx Plus: Prior Authorization Criteria and Step Therapy Requirements

Rx Premier: 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 Phone:  1-800-935-6103

Redetermination Appeal Fax: 1-877-328-9660

Expedited Redetermination Appeals can be done by phone: 1-800-935-6103

Customer Service Phone: 1-855-864-6797 (TTY: 1-800-716-3231)

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Silverscript (Choice, Plus Plans)

Silverscript Website

Formularies (Drug Lists):

Choice Plan

Plus Plan

Smart Rx Plan

Coverage Determination Form

Prior Authorization Criteria, Step Therapy Requirements

Choice Plan:  Prior Authorization Criteria and Step Therapy Requirements

Plus Plan:  Prior Authorization Criteria and Step Therapy Requirements

Smart Rx Plan:  Prior Authorization Criteria and Step Therapy Requirements

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 Phone:  1-866-235-5660 (TTY: 711)

Redetermination Appeal Fax: 1-855-633-7673

Expedited Redetermination (First level Appeal) Phone: 1-866-235-5660 (TTY: 711)

Customer Service Phone:  1-855-335-1407 (TTY: 711)

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

United Healthcare Website

Formularies (drug lists):

AARP Preferred

AARP Saver Plus

AARP Walgreens

Prior Authorization Criteria, Step Therapy Requirements:

AARP Preferred:  Prior Authorization Criteria and Step Therapy Requirements

AARP Saver Plus:  Prior Authorization Criteria and Step Therapy Requirements

AARP Walgreens:  Prior Authorization Criteria and Step Therapy Requirements

Coverage Determination Form

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

Coverage Determination (Prior Authorization) Fax:  1-844-403-1028

Redetermination (First Level Appeal) Form

Redetermination (First Level Appeal) Phone:  1-800-595-9532

Redetermination (First Level Appeal) Fax:  1-866-308-6294

Expedited Redetermination (First Level Appeal) Phone:  1-800-595-9532

Customer Service (Members):  1-800-556-7596

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WellCare (Classic, Rx Saver, Rx Select, Rx Value Plus, Value Script, Wellness Rx Plans)

WellCare Website

Formularies (Drug Lists):

Classic

Rx Saver

Rx Select

Rx Value Plus

Value Script

Wellness Rx

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 (First Level Appeal) Phone:  1-888-550-5252

Redetermination Fax: 1-866-388-1766

Expedited Redetermination Phone: 1-888-550-5252

Customer Service Phone: 1-888-550-5252

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 October 2019