Provider Information
- 2025 Provider Manual
- Participating Providers
- Participating Pharmacies
- Model of Care Training and Attestation
- 2025 Provider Quick Reference Guide
- Provider Information Update
- Provider EFT/ERA Enrollment Form
Medical Information and Authorization
Pharmacy Information and Authorization
Formulary 2025
- 2025 Formulary (List of Covered Drugs)
(last updated 11/5/2024) - 2025 Formulary (List of Covered Drugs) (Spanish)
(last updated 11/5/2024) - 2025 Prior Authorization Criteria
(last updated 11/19/2024) - 2025 Step Therapy Criteria
(last updated 11/19/2024) - 2025 Formulary (Prescription Drugs) Search Tool
- Online Part D Coverage Determination/Redetermination
- 2025 Provider Coverage Determination Form
Member Benefit Information
- 2025 Summary of Benefits for 001
(contains multi-language insert) - 2025 Summary of Benefits for 001 (Spanish)
- 2025 Summary of Benefits for 002
(contains multi-language insert) - 2025 Summary of Benefits for 002 (Spanish)