Drug Formulary

icon 2022 Medicare-Medicaid Plan/Dual Options Drug Formulary

icon 2021 Medicare-Medicaid Plan/Dual Options Drug Formulary

Additional Pharmacy Benefit Information

icon 2022 Prior Authorization for Pharmacy
icon 2022 Prior Authorization Grid
icon 2022 Step Therapy Grid

icon 2021 Prior Authorization for Pharmacy
icon 2021 Prior Authorization Grid
icon 2021 Step Therapy Grid

Click here if one of your patients is looking for the Coverage Determination Request Form, the Pharmacy Direct Member Reimbursement Form or other member forms.

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