RX Forms & Documents
Important medication documents for your plan.
Find the right forms for your plan.
- Appointment of Representative form
- Blood Glucose Test Strips Coverage
- D-SNP (HMO) formulary – English | Spanish (effective 04/01/2025)
- D-SNP (HMO) D-SNP Formulary Search Tool
- D-SNP (HMO) LIS Premium Summary Chart – English | Spanish
- D-SNP (HMO) Prior Authorization Criteria (effective 04/01/2025)
- D-SNP (HMO) Step Therapy Criteria
- Errata (List of Changes to D-SNP (HMO) Formulary) (effective 04/01/2025)
- Errata (List of Changes to HMO Formulary) (effective 04/01/2025)
- Errata (List of Changes to PPO Formulary) (effective 04/01/2025)
- HMO Comprehensive Formulary (effective 04/01/2025)
- HMO Formulary Search Tool
- HMO LIS Premium Summary Chart – English | Spanish
- HMO Paper Prescription Drug Coverage Determination Request – English | Spanish
- HMO Paper Prescription Drug Coverage Redetermination Request – English | Spanish
- HMO Prior Authorization Criteria (effective 04/01/2025)
- HMO Step Therapy Criteria
- Mail Order Pharmacy Form
- Maryland Pharmacy Directory HMO, D-SNP (HMO), and Virginia Select (HMO) – English | Spanish (effective 03/15/2025)
- Maryland Pharmacy Directory PPO, Plus (PPO) and Primary (PPO) (effective 03/15/2025)
- Medicare Part D Prescription Claim form
- Online Medicare Prescription Drug Coverage Determination Request
- Online Medicare Prescription Drug Coverage Redetermination Request
- Over the Counter (OTCHS) Catalog – English | Spanish
- Part B Medical Reimbursement Claim form
- Personal Medication List – English | Spanish
- Pharmacy Locator Tool
- Prescription Drug Formulary
- PPO and Plus (PPO) Comprehensive Formulary (effective 04/01/2025)
- PPO and Plus (PPO) Formulary Search Tool
- PPO and Plus (PPO) Prior Authorization Criteria
- PPO and Plus (PPO) Step Therapy Criteria
- PPO LIS Premium Summary Chart – English | Spanish
- PPO Paper Prescription Drug Coverage Determination Request – English | Spanish
- PPO Prescription Drug Coverage Redetermination Request – English | Spanish
- Primary (PPO) Comprehensive Formulary (effective 04/01/2025)
- Primary (PPO) Formulary Search Tool
- Select (HMO) Formulary (effective 04/01/2025)
- Select (HMO) Formulary Search Tool
- Select (HMO) LIS Premium Summary Chart
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