Medicare Part D


Medicare Prescription Drug (Part D) Resources & Links

Plan Premiums, Deductibles, and Cost Sharing

To find out more about our benefits, please click here to review our Summary of Benefits. The document highlights applicable premiums, co-payments, co-insurance, and deductibles. Please refer to the Evidence of Coverage for a complete explanation of our benefits.

Find a Pharmacy

Pharmacy Search

Find a Drug

Drug Search

Out of Network Coverage

Information about Out of Network Coverage including limits and financial responsibility. English or Español

Grievance, Coverage Determination or Appeal

The process for coverage decisions and appeals can be found in Chapter 9 of your evidence of coverage (EOC). This is the process you use for issues such as whether something is covered or not and the way in which something is covered. Please refer to Chapter 9 of your EOC for a full description of the process. Evidence of Coverage

You can also access this information by downloading Chapter 9 here.
English or Spanish

Drug Coverage Determination Form

File a Medicare Prescription Drug Coverage Determination Form Here.
Coverage Determination Request

Redetermination Request Form

File a Redetermination Request Form Here.
Redetermination Request

Prior Authorization Request Form

Prior Authorization Request Form

Appointment of Representative Form

Appointment of Representative Form (AOR) - (CMS-1696).
Click here

Medication Therapy Management Program (MTMP)

English or Español

Transition Process

English or Español

Prior Authorization Criteria

Click Here

Step Therapy Criteria

Click Here

Quality Assurance Policy

English or Español

Low Income Subsidy (LIS) Levels

English or Español