Prescription Drug Forms

Prescription Drug Resources and Documents

Check below for important information about the Part D Transition Process, Prior Authorizations, the Step Therapy Criteria for Part D Medicare, and the coverage determination and redetermination processes.

You can also find out more about getting Extra Help with your prescription drug coverage.

Prescription Drug Resources

Drug Formulary PDF

Download PDF: 2024 Plan Formulary – December 2024 (English/Spanish/Chinese) 2025 Plan Formulary – January 2025 (English/Spanish/Chinese)
Last updated: November 27, 2024

Future Formulary Changes

Please check these formulary updates for upcoming changes in the drug coverage list.
Download PDF: October 2024
Last updated: October 29, 2024

Requirements and Policies

Step Therapy Requirements

Download PDF: December 2024 January 2025
Last updated: November 27, 2024

Prior Authorization Requirements

Download PDF: December 2024 January 2025
Last updated: November 27, 2024

Prescription Drug Transition Policy

Download PDF: English Spanish Chinese
Last updated: June 7, 2023

Medicare Part D Opioid Policies

Download PDF: Opioid Pharmacist Tip Sheet
Last updated: November 25, 2020

Forms

Opioid Prior Authorization Request Form

Download PDF: Request Form
Last updated: November 25, 2020

Prescription Mail-Order Form/Brochure

Download PDF: English Spanish Chinese
Last updated: October 3, 2023

Request for Medicare Prescription Coverage Determination Form

Download PDF: Determination Form
Last updated: May 9, 2024

Request for Medicare Prescription Coverage Redetermination Form

Download PDF: Redetermination Form
Last updated: May 9, 2024

Last updated 11/27/2024.