Pharmacy Reference Materials and Forms

woman filing

Prescription Mail Order Form pdf icon

Step Therapy Criteria

Step Therapy Criteria (all plans) pdf icon

TexanPlus® HMO/HMO-POS (Houston/Beaumont)

Prior Authorization Criteria pdf icon

Medicare Part D Prescription Drug Claim Form pdf icon

Coverage of a Non-Formulary Drug pdf icon

Quantity Limit Exception pdf icon

Step Therapy Exception pdf icon

Lower Co-pay (Tiering Exception) pdf icon

TexanPlus HMO/HMO-POS Medicare Prescription Drug Coverage Determination form pdf icon 
To initiate a coverage determination online for TexanPlus HMO, please click here
To initiate a coverage determination online for TexanPlus HMO-POS, please click here.

TexanPlus HMO/HMO-POS Medicare Prescription Drug Appeal (Redetermination) form pdf icon  
To initiate a coverage redetermination online for TexanPlus HMO, please click here
To initiate a coverage redetermination online for TexanPlus HMO-POS, please click here.

Injectable Infusion Form pdf icon

Hospice Information for Medicare Part D Plans pdf icon

TexanPlus® HMO-SNP

Prior Authorization Criteria pdf icon

Medicare Part D Prescription Drug Claim Form pdf icon

Coverage of a Non-Formulary Drug pdf icon

Quantity Limit Exception pdf icon

Step Therapy Exception pdf icon

Lower Co-pay (Tiering Exception) pdf icon

TexanPlus HMO-SNP Medicare Prescription Drug Coverage Determination form pdf icon 
To initiate a coverage determination online, please click here.

TexanPlus HMO-SNP Medicare Prescription Drug Appeal (Redetermination) form pdf icon  
To initiate a coverage redetermination online, please click here.

Injectable Infusion Form pdf icon

Hospice Information for Medicare Part D Plans pdf icon

TexanPlus® HMO (Dallas/Ft. Worth)

Prior Authorization Criteria pdf icon

Medicare Part D Prescription Drug Claim Form pdf icon

Coverage of a Non-Formulary Drug pdf icon

Quantity Limit Exception pdf icon

Step Therapy Exception pdf icon

Lower Co-pay (Tiering Exception) pdf icon

TexanPlus HMO Medicare Prescription Drug Coverage Determination form pdf icon  
To initiate a coverage determination online, please click here.

TexanPlus HMO Medicare Prescription Drug Appeal (Redetermination) form pdf icon  
To initiate a coverage redetermination online, please click here.

Injectable Infusion Form pdf icon

Hospice Information for Medicare Part D Plans pdf icon

Today's Options® PPO

Prior Authorization Criteria pdf icon

Medicare Part D Prescription Drug Claim Form pdf icon

Coverage of a Non-Formulary Drug pdf icon

Quantity Limit Exception pdf icon

Step Therapy Exception pdf icon

Lower Co-pay (Tiering Exception) pdf icon

Today's Options PPO Medicare Prescription Drug Coverage Determination form pdf icon  
To initiate a coverage determination online, please click here.

Today's Options PPO Medicare Prescription Drug Appeal (Redetermination) form pdf icon  
To initiate a coverage redetermination online, please click here.

Injectable Infusion Form pdf icon

Hospice Information for Medicare Part D Plans pdf icon

Today's Options® PFFS

Prior Authorization Criteria pdf icon

Medicare Part D Prescription Drug Claim Form pdf icon

Coverage of a Non-Formulary Drug pdf icon

Quantity Limit Exception pdf icon

Step Therapy Exception pdf icon

Lower Co-pay (Tiering Exception) pdf icon

Today's Options PFFS Medicare Prescription Drug Coverage Determination form pdf icon  
To initiate a coverage determination online, please click here.

Today's Options PFFS Medicare Prescription Drug Appeal (Redetermination) form pdf icon  
To initiate a coverage redetermination online, please click here.

Injectable Infusion Form pdf icon

Hospice Information for Medicare Part D Plans pdf icon

Today's Options® HMO

Prior Authorization Criteria pdf icon

Medicare Part D Prescription Drug Claim Form pdf icon

Coverage of a Non-Formulary Drug pdf icon

Quantity Limit Exception pdf icon

Step Therapy Exception pdf icon

Lower Co-pay (Tiering Exception) pdf icon

Today's Options HMO Medicare Prescription Drug Coverage Determination form pdf icon  
To initiate a coverage determination online, please click here.

Today's Options HMO Medicare Prescription Drug Appeal (Redetermination) form pdf icon  
To initiate a coverage redetermination online, please click here.

Injectable Infusion Form pdf icon

Hospice Information for Medicare Part D Plans pdf icon

TexanPlus® HMO/HMO-POS (Houston/Beaumont)

Prescription Mail Order Form pdf icon

TexanPlus® HMO (Dallas/Ft. Worth)

Prescription Mail Order Form pdf icon

Today's Options® PPO/PFFS

Prescription Mail Order Form pdf icon

Today's Options® HMO

Prescription Mail Order Form pdf icon

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