Pharmacy Forms & Notices

Here’s a list of pharmacy documents and forms you may need when using your Medicare Part D benefit. If you have questions about these items, please contact Member Services. We’re here to help.

• Covered Diabetes Testing Supplies (DSNP) - (PDF)
• Covered Diabetes Testing Supplies (HMO) - (PDF)

• List of Drugs (Formulary)
• List of Drugs Change Notice
• Drug Coverage Determination (Exception)
• Drug Redetermination (Appeal)
• Part D Prior Authorization Criteria Form
• Part D Step Therapy Criteria Form
• Appointment of Representative Form - English (PDF)
• Appointment of Representative Form - Spanish (PDF)