This plan covers part or all of prescription drugs covered under Medicare Part B; see the Summary of Benefits for specific details. For drugs covered under Medicare Part D, this plan uses a formulary (a list of covered drugs). We have formed a network of pharmacies. To receive plan prescription drug benefits, you must use a network pharmacy, except in non-routine circumstances, and quantity limitations and restrictions may apply.
For the most recent list of drugs please call the number or visit the website listed on the back of your Member ID card.
Part D Prescription Drug Coverage Forms
Medicare Part D Prescription Claim Form
Request for Coverage of a Non-Formulary Drug
Request for Quantity Limit Exception
Request for Step Therapy Exception
Request for Lower Co-pay (Tiering Exception)
Request for a Medicare Prescription Drug Coverage Determination form
To initiate a coverage determination online, please click here (by
clicking on this link you will be leaving our website) Request for Medicare
Prescription Drug Appeal (Redetermination) form
To initiate a redetermination online, please click here (by clicking
on this link you will be leaving our website)
Part D Appeals, Grievances, Coverage Decisions and Appeals
We also list pharmacies that are in our network but are outside our coverage area.
A comprehensive formulary is a list of covered drugs selected by this plan. The formulary may
change during the year. We may periodically add, remove, or make changes to coverage
limitations on certain drugs or change how much you pay for a drug. If we make any
formulary changes that limit our members' ability to fill their prescriptions, we
will notify the affected members before the change is made. Read about formulary information and any restrictions to the formulary.
Comprehensive Formulary - No changes made since August 2014
Formulary Addendum - Updated August 2014
Apéndice del Formulario - Updated August 2014
Upcoming Formulary Changes
We will notify you of a formulary change at least 60 days before the date that the
change becomes effective. However, if the Food and Drug Administration (FDA) deems
a drug on our formulary to be unsafe, or if the drug's manufacturer removes the
drug from the market, we will immediately remove the drug from the formulary.
Medication Therapy Management Program
Medication Therapy Management (MTM) Programs
Prior Authorization and Step Criteria
Prior Authorization Criteria
Step Therapy Criteria
View a sample Transition Letter
Low Income Subsidy Premium Table
This chart shows what you might expect to pay for your plan premium if you qualify
for 100%, 75%, 50% or 25% Extra Help as a member. Note: the premiums listed in the
chart are for both medical services and prescription drug benefits.