Forms and Documents

2022 Annual Notice of Changes English | Spanish

2022 Member Handbook (includes document of coverage information) English | Spanish

2022 Drug List (Formulary) English | Spanish

2022 Provider and Pharmacy Directory English | Spanish

2022 Summary of Benefits English | Spanish

Critical Incident Form for Members English | Spanish

AllianceRx Walgreens Prime Mail-Order Form English | Spanish

Express Scripts^® Pharmacy Mail-Order Form English | Spanish

Drug Mail Order Form English | Spanish

Frequently Asked Questions English | Spanish

HIPAA Notice of Privacy Practices English | Spanish

Prescription Drug Transition Policy English | Spanish

Power of Attorney

Appointment of Representative English | Spanish

Quality Improvement Form English | Spanish

Request for Medicare Prescription Drug Coverage Determination

Request for Redetermination of Medicare Prescription Drug Denial

Request for Payment for Medicare Part D Drugs

Prior Authorization Criteria and Form

Quantity Limits Exception Form

Step Therapy Criteria and Form

View these forms and documents in Spanish. If you have questions, please Contact Us.