Language Assistance Available [pdf, 778 KB] Prescription Claim Form [pdf, 1750 KB] Prescription Mail Service Order Form [pdf, 1155 KB] If your policy has a mail-order drug benefit, use this form to order new and/or refill mail service prescriptions.Prior Approval Form for Prescription Drugs [pdf, 324 KB]
Essential Complete Formulary [pdf, 1860 KB] Essential Value Formulary [pdf, 1986 KB] Metallic Formulary [pdf, 6866 KB] Standard with Step Drug List [pdf, 1544 KB] Standard with Step Therapy Formulary [pdf, 2924 KB] Standard/Standard with Step Prior Approval List [pdf, 717 KB] Medications that require prior approval. For authorization, call 1-877-433-2973.
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