Prescription Drug Resources and Documents
Check below for important information about the Part D Transition Process, Prior Authorizations, the Step Therapy Criteria for Part D Medicare, and the coverage determination and redetermination processes.
You can also find out more about getting Extra Help with your prescription drug coverage.
Prescription Drug Resources
Prescription Drug Copay Table
Download PDF:
2025 Copay Table
Last updated: October 1, 2024
Drug Formulary PDF
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2024 Plan Formulary – October 2024 (English/Spanish/Chinese)
2025 Plan Formulary – January 2025 (English/Spanish/Chinese)
Last updated: September 27, 2024
Future Formulary Changes
Please check these formulary updates for upcoming changes in the drug coverage list.
Download PDF:
October 2024
Last updated: September 27, 2024
Requirements and Policies
Step Therapy Requirements
Last updated: September 27, 2024
Prior Authorization Requirements
Last updated: September 27, 2024
Prescription Drug Transition Policy
Medicare Part D Opioid Policies
Download PDF:
Opioid Pharmacist Tip Sheet
Last updated: November 25, 2020
Forms
Opioid Prior Authorization Request Form
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Request Form
Last updated: November 25, 2020
Prescription Mail-Order Form/Brochure
Request for Medicare Prescription Coverage Determination Form
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Determination Form
Last updated: May 9, 2024
Request for Medicare Prescription Coverage Redetermination Form
Download PDF:
Redetermination Form
Last updated: May 9, 2024