Language Assistance Available [pdf, 778 KB] Prescription Claim Form [pdf, 1406 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, 50 KB]
2018 Metallic Formulary [pdf, 3525 KB] 2019 Metallic Formulary [pdf, 3443 KB] 2018 Standard with Step Drug List [pdf, 1415 KB] 2018 Standard with Step Therapy Formulary [pdf, 1928 KB] 2019 Standard with Step Therapy Formulary [pdf, 1641 KB] Standard/Standard with Step Prior Approval List [pdf, 149 KB] Medications that require prior approval. For authorization, call 1-877-433-2973.
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