Provider Information
- 2024 Provider Manual
- Participating Providers
- Participating Pharmacies
- Model of Care Training and Attestation
- 2024 Provider Quick Reference Guide
- Provider Information Update
- Provider EFT/ERA Enrollment Form
Medical Information and Authorization
Pharmacy Information and Authorization
Formulary 2024
- 2024 Formulary (List of Covered Drugs)
(last updated 11/1/2024) - 2024 Formulary (List of Covered Drugs) (Spanish)
(last updated 11/1/2024) - 2024 Prior Authorization Criteria
(last updated 11/1/2024) - 2024 Step Therapy Criteria
(last updated 11/1/2024) - 2024 Formulary (Prescription Drugs) Search Tool
- Online Part D Coverage Determination/Redetermination
- 2024 Provider Coverage Determination Form
Member Benefit Information
- 2024 Summary of Benefits
(contains multi-language insert) - 2024 Summary of Benefits (Spanish)
Newsletters
Page Last Updated: 10/31/2024