Forms and Documents

• Annual Notice of Changes — Last Updated 10/01/2024
• Member Handbook (includes document of coverage information) — Last Updated 02/13/2025
• Provider and Pharmacy Directory — Last Updated 06/03/2025
• Quality Improvement Form — Last Updated 10/01/2024
• Summary of Benefits — Last Updated 10/01/2024

Pharmacy Forms and Documents

• Drug List (Formulary) — Last Updated 07/01/2025
• Express Scripts^® Pharmacy Mail-Order Form — Last Updated 10/01/2024
• Over-the-Counter (OTC) Benefit Catalog — Last Updated 01/01/2025
• Over-the-Counter (OTC) Product Order Form — Last Updated 01/01/2025
• Prescription Drug Transition Policy — Last Updated 10/01/2024
• Walgreens Mail Service Mail-Order Form — Last Updated 10/01/2024

Privacy Documents

• Appointment of Representative
• Critical Incident Form for Members — Last Updated 10/01/2024
• HIPAA Notice of Privacy Practices — Last Updated 10/01/2024
• Power of Attorney

Medicare & Medicaid Forms

• Request for Medicare Prescription Drug Coverage Determination
• Request for Payment for Medicare Part D Drugs
• Request for Redetermination of Medicare Prescription Drug Denial

Utilization Management Forms

• Prior Authorization Criteria and Form
• Quantity Limits Exception Form
• Step Therapy Criteria and Form

Other

• Adult Wellness Guidelines — Last Updated 10/01/2024
• Health Risk Screening — Last Updated 10/01/2024
• Material Notice — Last Updated 10/01/2024
• Perinatal (Pregnancy) Wellness Guidelines — Last Updated 10/01/2024
• Frequently Asked Questions — Last Updated 10/01/2024