RX Forms & Documents
Important medication documents for your plan.
Find the right forms for your plan.
- 2027 BMORE Balanced (HMO D-SNP) and D-SNP (HMO D-SNP) formulary (effective 01/01/2027)
- Blood Glucose Test Strips Coverage
- 2026 D-SNP (HMO D-SNP) formulary (effective 10/01/2026)
- 2027 BMORE Balanced (HMO D-SNP) and D-SNP (HMO D-SNP) Formulary Search Tool
- 2026 D-SNP (HMO D-SNP) Formulary Search Tool
- 2026 D-SNP (HMO D-SNP) Prior Authorization Criteria (effective 10/01/2026)
- 2026 D-SNP (HMO D-SNP) LIS Premium Summary Chart – English | Spanish
- 2027 BMORE Balanced (HMO D-SNP) and D-SNP (HMO D-SNP) Prior Authorization Criteria (effective 01/01/2027)
- 2027 BMORE Balanced (HMO D-SNP) and D-SNP (HMO D-SNP) Step Therapy Criteria
- 2026 D-SNP (HMO D-SNP) Step Therapy Criteria
- 2027 Errata (List of changes to BMORE Balanced (HMO D-SNP) and D-SNP (HMO D-SNP) Formulary) (effective 01/01/2027)
- 2026 Errata (List of Changes to D-SNP (HMO D-SNP) Formulary) (effective 10/01/2026)
- 2026 Errata (List of Changes to HMO Formulary) (effective 10/01/2026)
- 2027 Errata (List of Changes to HMO, Select (HMO) and Tribute (HMO) Formulary) (effective 01/01/2027)
- 2026 Errata (List of Changes to PPO Formulary) (effective 10/01/2026)
- 2027 Errata (List of Changes to PPO Formulary) (effective 01/01/2027)
- 2027 HMO, Select (HMO) and Tribute (HMO) Comprehensive Formulary (effective 01/01/2027)
- 2027 BMORE Balanced (HMO D-SNP) and D-SNP (HMO D-SNP) LIS Premium Summary Chart – English | Spanish
- 2026 D-SNP (HMO D-SNP) Grocery Catalog
- 2027 D-SNP (HMO D-SNP) Grocery Catalog
- 2026 HMO Comprehensive Formulary (effective 10/01/2026)
- 2027 HMO, Select (HMO) and Tribute (HMO) Formulary Search Tool
- 2026 HMO Formulary Search Tool
- 2027 HMO Paper Prescription Drug Coverage Determination Request – English | Spanish
- 2026 HMO LIS Premium Summary Chart – English | Spanish
- 2027 HMO LIS Premium Summary Chart
- 2026 HMO Paper Prescription Drug Coverage Determination Request – English | Spanish
- 2027 HMO Paper Prescription Drug Coverage Redetermination Request – English | Spanish
- 2026 HMO Paper Prescription Drug Coverage Redetermination Request – English | Spanish
- 2027 HMO Prior Authorization Criteria (effective 01/01/2027)
- 2026 HMO Prior Authorization Criteria (effective 10/01/2026)
- 2026 HMO Step Therapy Criteria
- 2027 HMO Step Therapy Criteria (effective 01/01/2027)
- 2026 Medicare Part D Prescription Claim form
- 2027 Mail Order Pharmacy Form
- 2026 Mail Order Pharmacy Form
- Spanish Pharmacy Directory (effective 09/15/2026)
- English Pharmacy Directory (effective 09/15/2026)
- 2027 Medicare Part D Prescription Claim form
- 2027 Online Medicare Prescription Drug Coverage Determination Request
- 2026 Online Medicare Prescription Drug Coverage Determination Request
- Online Medicare Prescription Drug Coverage Redetermination Request
- 2027 Online Medicare Prescription Drug Coverage Redetermination Request
- 2026 PPO and Plus (PPO) Comprehensive Formulary (effective 10/01/2026)
- 2027 Part B Medical Reimbursement Claim form
- 2026 Part B Medical Reimbursement Claim form
- 2027 Over the Counter Catalog – English | Spanish
- 2026 Over the Counter Catalog
- 2027 Personal Medication List – English | Spanish
- 2026 Personal Medication List – English | Spanish
- 2026 Pharmacy Locator Tool
- 2026 Prescription Drug Formulary
- 2027 Prescription Drug Formulary
- 2027 PPO, Access (PPO) and Plus (PPO) Comprehensive Formulary (effective 01/01/2027)
- 2026 PPO and Plus (PPO) Formulary Search Tool
- 2027 PPO, Access (PPO) and Plus (PPO) Formulary Search Tool
- 2026 PPO and Plus (PPO) Prior Authorization Criteria (effective 10/01/2026)
- 2027 PPO, Access (PPO) and Plus (PPO) Prior Authorization Criteria (effective 01/01/2027)
- 2026 Primary (PPO) Prior Authorization Criteria (effective 10/01/2026)
- 2027 PPO, Access (PPO) and Plus (PPO) Step Therapy Criteria (effective 01/01/2027)
- 2026 PPO and Plus (PPO) Step Therapy Criteria
- 2026 Primary (PPO) Step Therapy Criteria
- 2026 PPO Paper Prescription Drug Coverage Determination Request
- 2027 PPO LIS Premium Summary Chart
- 2026 PPO LIS Premium Summary Chart
- 2027 PPO Paper Prescription Drug Coverage Determination Request – English | Spanish
- 2026 PPO Prescription Drug Coverage Redetermination Request – English | Spanish
- 2027 PPO Prescription Drug Coverage Redetermination Request – English | Spanish
- 2026 Primary (PPO) Comprehensive Formulary (effective 10/01/2026)
- 2026 Primary (PPO) Formulary Search Tool
- 2026 Select (HMO) Formulary – English | Spanish (effective 10/01/2026)
- Select (HMO) Formulary Search Tool
- Appointment of Representative form
- 2026 Select (HMO) LIS Premium Summary Chart – English | Spanish
- 2027 Select (HMO) LIS Premium Summary Chart – English | Spanish
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