Pharmacy Reference Materials and Forms

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Prescription Mail Order Form pdf icon

Medicare Part D Prescription Drug Claim Form pdf icon

Prior Authorization Criteria

PA Criteria – TexanPlus HMO/ HMO-POS/ HMO-SNP (Houston/ Beaumont) pdf icon

PA Criteria –TexanPlus HMO (Dallas/ Ft. Worth), Today’s Options PPO/ PFFS pdf icon

Step Therapy Criteria

Step Therapy Criteria (all plans) pdf icon

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

Coverage of a Non-Formulary Drug (TexanPlus HMO) pdf icon

Coverage of a Non-Formulary Drug (TexanPlus HMO-POS) pdf icon

Coverage of a Non-Formulary Drug (TexanPlus HMO-SNP) pdf icon

Quantity Limit Exception (TexanPlus HMO) pdf icon

Quantity Limit Exception (TexanPlus HMO-POS) pdf icon

Quantity Limit Exception (TexanPlus HMO-SNP) pdf icon

Step Therapy Exception (TexanPlus HMO) pdf icon

Step Therapy Exception (TexanPlus HMO-POS) pdf icon

Step Therapy Exception (TexanPlus HMO-SNP) pdf icon

Lower Co-pay (Tiering Exception) (TexanPlus HMO) pdf icon

Lower Co-pay (Tiering Exception) (TexanPlus HMO-POS) pdf icon

Lower Co-pay (Tiering Exception) (TexanPlus HMO-SNP) 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.

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.

TexanPlus® HMO (Dallas/Ft. Worth)

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.

Today's Options® PPO

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.

Today's Options® PFFS

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.

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