Formulary Links, Forms and Contacts

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Anthem (MediBlue Enhanced, MediBlue Rx Plus, MediBlue Rx Standard)

Anthem Website

Formularies (drug lists):

MediBlue Enhanced

MediBlue Rx Plus

MediBlue Rx Standard

Prior Authorization Criteria, Step Therapy Requirements:

MediBlue Enhanced: Prior Authorization Criteria and Step Therapy Requirements

MediBlue Rx Plus: Prior Authorization Criteria and Step Therapy Requirements

MediBlue Rx Standard: Prior Authorization Criteria and Step Therapy Requirements

Coverage Determination Form

Coverage Determination (Prior Authorization) Phone: 1-833-293-0661

Coverage Determination (Prior Authorization) Fax: 1-844-521-6938

Redetermination (First Level Appeal) Form

Redetermination (First Level Appeal) Phone:  1-866-755-2776

Redetermination (First Level Appeal) Fax: 1-888-458-1407

Expedited Redetermination (First Level Appeal) Phone:  1-866-755-2776

Customer Service Line (Members): 1-866-755-2776

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Cigna-Healthspring Rx (Secure, Secure-Extra, Secure-Essential)

Cigna-Healthspring Website

Formularies (drug lists):

Secure Plan Formulary

Secure-Extra Plan Formulary

Secure-Essential Plan Formulary

Coverage Determination (Prior Authorization) Form

Prior Authorization Criteria, Step Therapy Requirements

Secure:  Prior Authorization Criteria and Step Therapy Requirements

Secure-Extra:  Prior Authorization Criteria and Step Therapy Requirements

Secure-Essential:  Prior Authorization Criteria and Step Therapy Requirements

Coverage Determination (Prior Authorization) Phone: 1-800-222-6700

Coverage Determination (Prior Authorization) Fax: 1-866-845-7267

Redetermination (First Level Appeal) Form

Redetermination Appeal Phone:  1-800-222-6700

Redetermination Appeal Fax: 1-866-593-4482

Expedited Redetermination Appeal Phone: 1-800-222-6700

Customer Service (Members): 1-800-222-6700

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Envision (EnvisionRx Plus Plan)

EnvisionRx Plus Website

Envision Rx Plus Formulary (drug list)

Coverage Determination (Prior Authorization) Form

Prior Authorization Criteria, Step Therapy Requirements, and Quantity Limits Criteria

Coverage Determination (Prior Authorization) Phone: 1-866-250-2005 (TTY/TDD 711)

Coverage Determination (Prior Authorization) Fax: 1-877-503-7231

Redetermination (First Level Appeal) Form

Redetermination (First Level Appeal) Fax: 1-877-503-7231

Expedited Redetermination (First Level Appeal) Phone: 1-866-250-2005

Customer Service Phone (Members): 1-866-250-2005 (TTY/TDD 711)

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Express Scripts Medicare (Value, Choice, Saver Plans)

Express Scripts Website

Formularies (drug lists):

Value Plan

Choice Plan

Saver Plan

Coverage Determination Form

Prior Authorization Criteria, Step Therapy Requirements

Value Plan:  Prior Authorization Criteria and Step Therapy Requirements

Choice Plan:  Prior Authorization Criteria and Step Therapy Requirements

Saver Plan:  Prior Authorization Criteria and Step Therapy Requirements

Coverage Determination (Prior Authorization) Phone: 1-844-374-7377 (TTY/TDD 1-800-716-3231)

Coverage Determination (Prior Authorization) Fax: 1-877-251-5896

Redetermination (First Level Appeal) Form

Redetermination Appeal Phone: 1-844-374-7377 (TTY 1-800-716-3231)

Redetermination Appeal Fax: 1-877-852-4070

Customer Service Phone (Members): 1-888-398-5899 (TTY 1-800-716-3231)

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Humana (Basic, Premier, Walmart Value Plans)

Humana Website

Formularies (Drug Lists):

Basic Plan

Premier Plan

Humana Walmart Value Plan

Coverage Determination Form

Prior Authorization Criteria, Step Therapy Requirements

Basic Plan:  Prior Authorization Criteria and Step Therapy Requirements

Premier Plan:  Prior Authorization Criteria and Step Therapy Requirements

Humana Walmart Value Plan:  Prior Authorization Criteria and Step Therapy Requirements

Coverage Determination (Prior Authorization) Phone: 1-800-555-2546

Coverage Determination (Prior Authorization) Fax: 1-877-486-2621

Redetermination (First Level Appeal) Form

Redetermination Appeal Phone:  1-800-457-4708

Redetermination Appeal Fax:  1-800-949-2961

Expedited Redetermination Appeal Phone:  1-800-867-6601

Expedited Redetermination Appeal Fax:  1-800-949-2961

Customer Service Phone: 1-800-457-4708 (TTY 711)

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Mutual of Omaha (Rx Plus, Rx Value Plans)

Mutual of Omaha Website

Formularies (Drug Lists):

Rx Plus

Rx Value

Coverage Determination Form

Prior Authorization Criteria, Step Therapy Requirements

Rx Plus: Prior Authorization Criteria and Step Therapy Requirements

Rx Value: Prior Authorization Criteria and Step Therapy Requirements

Coverage Determination (Prior Authorization) Phone: 1-844-374-7377 (TTY:  1-800-716-3231)

Coverage Determination (Prior Authorization) Fax: 1-877-328-9660

Redetermination (First Level Appeal) Form

Redetermination Appeal Phone:  1-844-374-7377 (TTY:  1-800-716-3231)

Redetermination Appeal Fax: 1-877-328-9660

Expedited Redetermination Appeals can be done by phone: 1-844-374-7377 (TTY: 1-800-716-3231)

Customer Service Phone: (TTY: 1-800-716-3231)

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Silverscript (Choice, Plus Plans)

Silverscript Website

Formularies (Drug Lists):

Choice Plan

Plus Plan

Coverage Determination Form

Prior Authorization Criteria, Step Therapy Requirements

Choice Plan:  Prior Authorization Criteria and Step Therapy Requirements

Plus Plan:  Prior Authorization Criteria and Step Therapy Requirements

Quantity Limit Exception Form

Coverage Determination (Prior Authorization) Phone: 1-866-235-5660 (TTY: 711)

Coverage Determination (Prior Authorization) Fax: 1-855-633-7673

Quantity Limit Exception Phone:  1-855-344-0930

Quantity Limit Exception Fax:  1-855-633-7673

Redetermination (First Level Appeal) Form

Redetermination Appeal Phone:  1-866-235-5660 (TTY: 711)

Redetermination Appeal Fax: 1-855-633-7673

Expedited Redetermination (First level Appeal) Phone: 1-866-235-5660 (TTY: 711)

Customer Service Phone:  1-866-235-5660 (TTY: 711)

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United Healthcare (AARP Preferred, AARP Saver Plus, AARP Walgreens)

United Healthcare Website

Formularies (drug lists):

AARP Preferred

AARP Saver Plus

AARP Walgreens

Prior Authorization Criteria, Step Therapy Requirements:

AARP Preferred:  Prior Authorization Criteria and Step Therapy Requirements

AARP Saver Plus:  Prior Authorization Criteria and Step Therapy Requirements

AARP Walgreens:  Prior Authorization Criteria and Step Therapy Requirements

Coverage Determination Form

Coverage Determination (Prior Authorization) Phone:  1-800-850-6807

Coverage Determination (Prior Authorization) Fax:  1-800-527-0531

Redetermination (First Level Appeal) Form

Redetermination (First Level Appeal) Phone:  1-800-595-9532

Redetermination (First Level Appeal) Fax:  1-866-308-6294

Expedited Redetermination (First Level Appeal) Phone:  1-800-595-9532

Customer Service (Members):  1-800-850-6807

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WellCare (Classic, Rx Saver, Rx Select, Value Plus, Value Script, Wellness Rx Plans)

WellCare Website

Formularies (Drug Lists):

Classic

Rx Saver

Rx Select

Value Plus

Value Script

Wellness Rx

Coverage Determination Form

Coverage Determination (Prior Authorization) Phone: 1-888-550-5252

Coverage Determination (Prior Authorization) Fax: 1-866-388-1767

Redetermination (First Level Appeal) Form

Redetermination Fax: 1-866-388-1766

Expedited Redetermination Phone: 1-888-550-5252

Customer Service Phone: 1-888-550-5252

Pharmacy Provider Phone: 1-888-550-5252

 

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MaineCare Member Services: 1-855-797-4357

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), scroll down to "Downloads" and click on "Model Coverage Determination Request Forms and Instructions". This form can be used with any Medicare Part D Plan.

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Updated October 2019