Drug Formulary

icon_pdf 2024 Medicare-Medicaid Plan/Dual Options Drug Formulary

Additional Pharmacy Benefit Information

icon_pdf 2024 Prior Authorization Grid

icon_pdf 2024 Step Therapy Grid

icon_pdf 2024 Medicare Part D Drug (J-Code) Step Therapy Grid

icon_pdf Request for Medicare Prescription Drug Coverage Determination

icon_pdf Request for Redetermination of Medicare Prescription Drug Denial

icon_pdf Direct Member Reimbursement Form

 

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