- Anthem (MediBlue Rx Plus, MediBlue Standard Plans)
- Cigna (Assurance Rx, Extra Rx, Saver Rx Plans)
- Clear Spring Health (Premier Rx, Value Rx)
- Humana (Basic, Premier, Value Plans)
- SilverScript (Choice)
- United Healthcare (AARP Preferred, AARP Saver)
- WellCare (Classic, Rx Value Plus, Value Script Plans)
- MaineCare links / CMS standard form
Anthem (MediBlue Rx Plus, MediBlue Rx Standard)
Formularies (drug lists):
Prior Authorization Criteria, 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 (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: 1-888-458-1406
Expedited Redetermination (First Level Appeal) Phone: 1-866-755-2776 (TTY 711)
Customer Service Line (Members): 1-866-755-2776 (TTY 711)
Cigna (Secure Rx, Extra Rx, Saver Rx)
Formularies (drug lists):
Prior Authorization Criteria, Step Therapy Requirements
Assurance Rx: Prior Authorization Criteria and Step Therapy Requirements
Extra Rx: Prior Authorization Criteria and Step Therapy Requirements
Saver Rx: Prior Authorization Criteria and Step Therapy Requirements
Coverage Determination (Prior Authorization) Form
Coverage Determination (Prior Authorization) Phone: 1-800-417-8164
Coverage Determination (Prior Authorization) Fax: 1-877-251-5896
Redetermination (First Level Appeal) Form
Redetermination Appeal Phone: 1-877-813-5595
Redetermination Appeal Fax: 1-866-593-4482
Expedited Redetermination Appeal Phone: 1-877-813-5595
Customer Service (Members): 1-800-997-1654 (TTY 711)
Clear Spring Health (Value Rx)
Formularies (drug lists):
Premier Rx Plan
Value Rx Plan
Coverage Determination (Prior Authorization) Form
Prior Authorization Criteria, Step Therapy Requirements
Premier Rx: Prior Authorization Criteria and Step Therapy Requirements
Value Rx: Prior Authorization Criteria and Step Therapy Requirements
Coverage Determination (Prior Authorization) Phone: 1-800-417-8164
Coverage Determination (Prior Authorization) Fax: 1-877-251-5896
Redetermination (First Level Appeal) Form
Redetermination Appeal Phone: 1-800-417-8164
Redetermination Appeal Fax: 1-877-251-5896
Expedited Redetermination Appeal Phone: 1-800-417-8164
Customer Service (Members): 1-877-317-6082 (TTY 711)
Humana (Basic, Premier, Walmart Value Plans)
Formularies (Drug Lists):
Prior Authorization Criteria, Step Therapy Requirements
Basic Plan: Prior Authorization Criteria and Step Therapy Requirements
Premier Plan: Prior Authorization Criteria and Step Therapy Requirements
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: 1-800-535-0462
Redetermination Appeal Fax: 1-877-556-7005
Expedited Redetermination Appeal Phone: 1-800-867-6601
Customer Service Phone: 1-800-457-4708 (TTY 711)
SilverScript (Choice)
Formularies (Drug Lists):
Prior Authorization Criteria, Step Therapy Requirements
Choice Plan: Prior Authorization Criteria and Step Therapy Requirements
Coverage Determination (Prior Authorization) Phone: 1-800-414-2386 (TTY 711)
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: 1-855-355-1407 (TTY: 711)
United Healthcare (AARP Preferred, AARP Saver)
Formularies (drug lists):
Prior Authorization Criteria, Step Therapy Requirements:
AARP Preferred: Prior Authorization Criteria and Step Therapy Requirements
AARP Saver: Prior Authorization Criteria and Step Therapy Requirements
Coverage Determination (Prior Authorization) Phone: 1-800-595-9532
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): 1-800-595-9532
WellCare (Classic, Value Plus, Value Script)
Formularies (Drug Lists):
Prior Authorization Criteria, Step Therapy Requirements:
Classic: Prior Authorization Criteria and Step Therapy Requirements
Value Plus: Prior Authorization Criteria and Step Therapy Requirements
Value Script: Prior Authorization Criteria and Step Therapy Requirements
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 (TTY: 711)
Customer Service Phone: 1-888-550-5252 (TTY: 711)
Pharmacy Provider Phone: 1-888-550-5252
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), 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.
Updated November 2023
