Prescription Drug Information & Documents

• Request for Medicare Prescription Drug Coverage Determination form
• Request for Redetermination of Medicare Prescription Drug Denial form
• 2024 Comprehensive Formulary, last updated 4/1/2024 - English | Spanish
• 2024 Step Therapy criteria
• 2024 Prior Authorization criteria
• Part B Step Therapy and Prior Authorization Criteria

Click here to use our drug look up tool to view a list of covered medications and costs.

If you would like a friend, relative, your doctor or other provider, or other person to be your representative to ask for a coverage decision or make an appeal, please contact Member Services by calling 1-833-866-6559 (TTY users should call 1-800-955-8770). From October 1 through March 31, we are open 8 a.m. – 8 p.m. local time, seven days a week, except for Thanksgiving and Christmas. From April 1 through September 30, we are open 8 a.m. – 8 p.m. local time, Monday – Friday, except for major holidays. Ask for the “Appointment of Representative” form. This form is also available on Medicare’s website via the link below. The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must send us a copy of the signed form. Instructions on where to send the form are included in the form

• CMS Appointment of Representative form