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Prescription Drug Forms

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

Plan Future Formulary Changes

Please check these formulary updates for upcoming changes in the drug coverage list.
Download PDF: October 2024
Last updated: October 29, 2024

Requirements and Policies

Step Therapy Requirements

Download PDF:
December 2024
January 2025
Last updated: November 27, 2024

Prior Authorization Requirements

Download PDF:
December 2024
January 2025
Last updated: November 27, 2024

Prescription Drug Transitional Care Policy

Download PDF: English Spanish Chinese
Last updated: June 7, 2023

Medicare Part D Opioid Policies

Last updated: November 25, 2020

Forms

Opioid Prior Authorization Request Form

Download PDF: Request Form
Last updated: November 25, 2020

Prescription Mail-Order Form/Brochure

Download PDF: English Spanish Chinese
Last updated: October 3, 2023

Request for Medicare Prescription Coverage Determination Form

Download PDF: Determination Form
Last updated: May 9, 2024

Request for Medicare Prescription Coverage Redetermination Form

Download PDF: Redetermination Form
Last updated: May 9, 2024