Formulary Information
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2010 Formulary Changes
PDF | 30 KB
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This list includes drugs that were added to or deleted from the formulary. This will help you talk with your doctor about the drugs you take and how you might save money.
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Value Formulary Program
PDF | 28 KB
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Value Formulary Drugs (Tier 0) - Special $0 copay program for qualified members.
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Self-administered Injectable Formulary
PDF | 76 KB
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This is a list of drugs that are used for limited medical conditions and are injected. It includes those we cover and formulary alternatives to non-covered drugs. This will help you talk with your doctor about the drugs you take and how you might save money.
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The Formulary Foundation
PDF | 20 KB
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A formal overview of our pharmacy program and how decisions are made.
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Generic Drugs
PDF | 8 KB
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This contains important information concerning generic drugs including myths and facts.
Prior Auth, Step Therapy, & Quantity Information
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Prior Authorization List
PDF | 108 KB
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Some drugs require prior approval, or prior authorization of coverage, before we will cover their cost. This is the list of drugs that require prior authorization. Your doctor needs to check this list and get approval before prescribing these drugs.
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Step Therapy List
PDF | 97 KB
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Stepped therapy means that certain “steps” or actions need to be followed for some drugs to be covered. This document lists the drugs that require stepped therapy. Your doctor needs to check this list and follow the steps before prescribing these drugs.
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Prior Authorization Criteria
ZIP | 3 MB
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These documents are specific to each drug that requires prior authorization. Each document lists the information we need before we will approve coverage.
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Prior Authorization Forms
ZIP | 1.2 MB
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These forms are used by providers to request prior authorization for drugs.
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Self-admin. Injectable Prior Auth. Forms
ZIP | 2 MB
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These forms are used by providers to request authorization for drugs that are injectable.
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Quantity Level Limit List
PDF | 168 KB
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For some drugs, we limit the number of pills or units that are covered by the benefit plan within a certain period of time. This list includes drugs that have quantity limits. It will help you understand how fills and refills work.
Forms & Mail Order
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Medco Mail-Order Form
PDF I 60 KB
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Use this form to submit new prescriptions for mail-order fulfillment.
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Health, Allergy & Medication Questionnaire (HMQ)
PDF | 55 KB
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Fill this form out and return it with the first mail-order form you send to Medco.
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Mail-Order Exclusion List
PDF | 11 KB
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Some prescriptions cannot be filled through the mail-order pharmacy. This document lists those drugs.
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Medco - Prescription Drug Reimbursement Form
PDF | 41 KB
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Use this form to request reimbursement for prescriptions.
