Formulary Links, Forms and Contacts

 

 

Anthem (MediBlue Rx Plus, MediBlue Rx Standard)

Anthem Website

Formularies (drug lists):

MediBlue Rx Plus

MediBlue Rx Standard

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 Form

Coverage Determination (Prior Authorization) Phone: 1-866-755-2776  (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: 1-888-458-1407

Expedited Redetermination (First Level Appeal) Phone:  1-866-755-2776  (TTY 711)

Customer Service Line (Members): 1-866-755-2776  (TTY 711)

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Cigna (Secure Rx, Extra Rx, Saver Rx)

Cigna Website

Formularies (drug lists):

Secure Rx Plan

Extra Rx Plan

Saver Rx Plan 

Coverage Determination (Prior Authorization) Form

Prior Authorization Criteria, Step Therapy Requirements

Secure 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) Phone: 1-877-222-6700

Coverage Determination (Prior Authorization) Fax: 1-877-251-5896

Redetermination (First Level Appeal) Form

Redetermination Appeal Phone:  1-866-845-6962

Redetermination Appeal Fax: 1-866-593-4482

Expedited Redetermination Appeal Phone: 1-866-845-6962

Customer Service (Members): 1-800-997-1654 (TTY 711)

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Clear Spring Health (Value Rx)

Clear Spring Health Website

Formularies (drug lists):

Value Rx Plan

Coverage Determination (Prior Authorization) Form

Prior Authorization Criteria, 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)

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Humana (Basic, Premier, Walmart Value Plans)

Humana Website

Formularies (Drug Lists):

Basic Plan

Premier Plan

Walmart Value Plan

Coverage Determination Form

Prior Authorization Criteria, Step Therapy Requirements

Basic Plan:  Prior Authorization Criteria and Step Therapy Requirements

Premier Plan:  Prior Authorization Criteria and Step Therapy Requirements

Walmart 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:  1-877-320-1235

Redetermination Appeal Fax:  1-866-556-2128

Expedited Redetermination Appeal Phone:  1-800-867-6601

Expedited Redetermination Appeal Fax:  1-877-556-7005

Customer Service Phone: 1-800-457-4708 (TTY 711)

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Mutual of Omaha (Rx Plus, Rx Premier, Rx Essential Plans)

Mutual of Omaha Website

Formularies (Drug Lists):

Rx Plus

Rx Premier

Rx Essential

Coverage Determination Form

Prior Authorization Criteria, Step Therapy Requirements

Rx Plus: Prior Authorization Criteria and Step Therapy Requirements

Rx Premier: Prior Authorization Criteria and Step Therapy Requirements

Rx Essential: Prior Authorization Criteria and Step Therapy Requirements

Coverage Determination (Prior Authorization) Phone: 1-800-935-6103

Coverage Determination (Prior Authorization) Fax: 1-877-251-5896

Redetermination (First Level Appeal) Form

Redetermination Appeal Phone:  1-800-935-6103 (TTY: 1-800-716-3231)

Redetermination Appeal Fax: 1-877-852-4070

Expedited Redetermination Appeals can be done by phone: 1-800-935-6103 (TTY: 1-800-716-3231)

Customer Service Phone: 1-855-864-6797 (TTY: 1-800-716-3231)

 

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SilverScript (Choice, Plus, SmartSaver)

SilverScript Website

Formularies (Drug Lists):

Choice Plan

Plus Plan

SmartSaver Plan

Coverage Determination Form

Prior Authorization Criteria, Step Therapy Requirements 

Choice Plan:  Prior Authorization Criteria and Step Therapy Requirements

Plus Plan:  Prior Authorization Criteria and Step Therapy Requirements

SmartSaver Plan:  Prior Authorization Criteria and Step Therapy Requirements

Coverage Determination (Prior Authorization) Phone: 1-800-414-2386

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:  1-866-235-5660 (TTY: 711)

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United Healthcare (AARP Preferred, AARP Saver, AARP Walgreens)

United Healthcare Website

Formularies (drug lists):

AARP Preferred

AARP Saver 

AARP Walgreens

Prior Authorization Criteria, Step Therapy Requirements:

AARP Preferred:  Prior Authorization Criteria and Step Therapy Requirements

AARP Saver:  Prior Authorization Criteria and Step Therapy Requirements

AARP Walgreens:  Prior Authorization Criteria and Step Therapy Requirements

Coverage Determination Form

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

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WellCare (Classic, Value Plus, Value Script)

WellCare Website

Formularies (Drug Lists):

Classic

Value Plus

Value Script

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 Form

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

 

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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.

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Updated November 2023