Formulary Links and Forms:
All 2012 Medicare Part D Plans in Maine
- Aetna (Aetna-CVS, Aetna Medicare Rx Premier Plans)
- Anthem (Blue Standard, Blue Premier, Blue Plus Plans)
- Cigna (Cigna Plan One)
- Community CCRx (Basic, Choice Plans)
- EnvisionRx Plus (Envision Rx Plus Silver, Rite Aid Envision Rx Plus)
- First Health (Premier, Premier Plus Plans)
- Health Net (Orange, Option One; Value Orange, Option Two Plans)
- HealthSpring (HealthSpring Prescription Drug Plan-Reg 1)
- Humana (Humana-Walmart-Preferred, Humana Enhanced Plans)
- Medco (Choice and Value Plans)
- Silverscript (CVS Caremark Value, CVS Caremark Plus Plans)
- United American (Preferred and Select Plans)
- United Healthcare (AARP Preferred, AARP Enhanced Plans)
- WellCare (Signature, Classic Plans)
- MaineCare links / CMS standard form
Aetna (Aetna-CVS, Aetna Medicare Rx Premier Plans)
Aetna Website
Prior Authorization (Coverage Determination) Form
Aetna Formulary Search Tool
Directions:
Step 1: Click on Medicare Plans
Step 2: Choose Three Tier Open Formulary
Step 3: Click on “Medicare Medication Search”
Step 4: Begin Searching by Drug or Therapeutic Class
Prior Authorization Line: 1-800-414-2386
Customer Service: 1-800-529-5586
Members: 1-877-238-6211
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Anthem (Blue Standard, Blue Premier, Blue Plus Plans)
Anthem Website
Prior Authorization (Coverage Determination) form and criteria
Formulary List and Drug Search Tool
Click on National Prescription Drug Plan
Prior Authorization forms are also available by contacting
Anthem PA line: 1-800-338-6180
Customer Service Line: 1-866-755-2776
Member Services: 1-800-482-0966
Prior Authorization Line (Express Scripts): 1-800-338-6180
Prior Authorization Fax: 1-888-831-2243
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Cigna (Cigna Plan One)
Cigna Website
Cigna Formulary Search Tool (For .pdf versions of Plan One and Plan Two, follow links.)
Standard Forms
Prior Authorization (Coverage Determination) Form
Prior Authorization Line: 1-800-558-9363
Customer Service / Members: 1-800-735-1459 or 1-800-222-6700
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Community CCRx (Basic, Choice Plans)
Community CCRx Website
Physician/Pharmacy Support Line: 1-866-684-5395 or TTY/TDD 1-866-684-5351 (Mon. – Sat. 7:00am to 10:30pm ET)
Links to Comprehensive Formularies and Drug Search Tool
Prior Authorization (Coverage Determination) Forms
Prior Authorization(Coverage Determination) Provider Phone Line : 1-866-316-6049
Prior Authorization (Coverage Determination), and Appeals Fax: 1-866-868-0858
Customer Service/Members: 1-866-684-5353
(TTY/TTD) 1-866-864-5351
EnvisionRx Plus (Envision Rx Plus Silver, Rite Aid Envision Rx Plus)
EnvisionRx Plus website
Prior Authorization
(Coverage Determination) Form
Appeals and Grievance Information and Drug-specific Forms
Silver
Plan Formulary Link
Rite Aid Envision Rx Plus Formulary Link
Prior
Authorization, Quantity Limit and Step Therapy Information
Member Services: 1-866-250-2005
Prior Authorization (Coverage Determination), Appeals and Grievance Fax:
1-877-503-7231
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First Health (Premier, Premier Plus, Value Plus Plans)
First Health Premier Website
Providers Website
2012 Premier, Premier Plus and Value Plus Formularies
Find your 2012 Plan and click on “Printable Comprehensive Formulary” or click on “Online Searchable Formulary”
Forms:
Standard Prior Authorization (Coverage Determination) Form
Instuructions for Prior Authorization (Coverage Determination)
form and Appeals and Grievance Procedures and Forms
Prior Authorization Line: 1-800-551-2694
Exceptions / Prior Authorizations Fax: 1-800-639-9158
Customer Service: 1-800-588-3322
Members: 1-866-865-0662
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Health Net (Orange Option One and Value Orange Option Two Plans)
Health Net
Website
Comprehensive Formulary (.pdf)
Prior Authorization Line: 1-800-867-6564
Prior Authorization Fax: 1-800-977-8226
Customer Service/Members: 1-800-606-3604 or 1-800-949-0166
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HealthSpring (Health Prescription Drug Plan, Reg 1)
HealthSpring Website
Formulary and Drug Search
Click on find a drug to check for specific drugs
Click on National Prescription Drug Plan for the full 2012 Formulary
Prior Authorization (Coverage Determination) forms, criteria and procedures
Prior Authorization Line: 1-800-331-6293
Prior Authorization Fax: Standard 1-866-845-7267; Expedited 1-866-593-4407
Customer Service Line: 1-888-299-3582
Members Line: 1-800-331-6293
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Humana (Humana-Walmart Preferred Rx, Humana Enhanced Plans)
Humana Website
Humana Formulary Search Tool
Forms:
Prior Authorization (Coverage Determination) Form
Prior Authorization Line: 1-800-555-2546
Prior Authorization Fax: 1-877-486-2621
First Level Appeal Fax: 1-800-949-2961
Customer Service: 1-800-706-0872
Members: 1-800-281-6918
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Medco (Choice and Value Plans)
Medco Website
Prior Authorization (Coverage Determination) Form
Prior Authorization Fax Line: 1-800-837-0959
Prior Authorization Line: 1-800-753-2851
Customer Service/Members: 1-800-758-4531
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Silverscript (CVS Caremark Value, CVS Caremark Plus Plans)
SilverScript Website
Silverscript Formulary
Click on "Comprehensive Formulary" (for .pdf versions of the Value and the Plus Plans' formularies) or "Formulary Search" (to search for covered drugs)
Prior Authorization (Coverage Determination) Form
Exceptions and Prior Authorizations: 1-800-294-5979
Exceptions Fax: 1-866-884-9475
Customer Service: 1-866-552-6106; TTY Users: 1-866-552-6282
Members: 1-866-235-5660; TTY Users: 1-866-236-1089
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United American: UA (Preferred, Select Plans)
Website Link
Formulary, Search Tool,
Prior Authorization, Quantity Limit and Step Therapy Guideline Link
Click on your Plan (Preferred or Select)
Prior Authorization (Coverage Determination) form and Other Forms Links
Customer Service: 1-866-524-4169
Pharmacy/Prior Authorization Line (Medco): 1-800-753-2851
Prior Authorization Fax: 1-800-711-5673
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United Healthcare: (AARP Preferred, AARP Enhanced Plans)
AARP Medicare Rx Plan Website
Prescription Drug Search Tool
Comprehensive Formularies and Criteria for Prior Authorizations, Step Therapy
Prior Authorization (Coverage Determination) Form
Prior Authorization Phone(Prescription Solutions): 1-800-711-4555
Prior Authorization Fax: 1-800-527-0531
Customer Service: 1-866-255-4835
Members: 1-888-867-5575
SPAP members (SPAP means Maine residents with Medicare and full MaineCare, the Buy In,
and/or the Drugs for the Elderly program): 1- 877-710-5083
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WellCare (Signature, Classic Plans)
WellCare Website
Pharmacist/Physician/Member Number: 1-866-800-6111; Members choose Option 1; Pharamacists choose Option 2; Physicians choose Option 3;
TTY/TDD 1-888-816-5252
WellCare Formulary Search Tools
(click on button for specific plan)
Signature
and Classic Plan Comprehensive Formulary Link
Coverage Determination
Form
First Level Appeal (Redetermination) Form
Various Other Forms
Coverage Determination (Prior Authorization) Fax 1-866-388-1767
Appeals Fax: 1-866-388-1766
Customer Service: 1-888-547-5252
(TTY/TTD) 1-888-816-5252
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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) under Medicare Part D, together with
instructions for completing the form. This form can be used with any Medicare Part D Plan.
