English documents

Mail order, automatic payment and claims documents

Coverage decision, redetermination and exception documents

Coverage determinations
Use the forms below to request a coverage decision (sometimes called a prior authorization or an exception) if you take a drug that isn't covered by our plan. Read more about coverage decisions. Coverage redeterminations
If you are appealing a previously denied coverage decision, use the forms below. Drug exception forms
If you would like to request a coverage exception, use the applicable form below. Step therapy criteria information
Some drugs on our drug list have step therapy requirements that must be met before we will cover the drug. Find out more about step criteria requirements for your plan below. Prior authorization criteria information
Some drugs on our drug list have prior authorization requirements that must be met before we will cover the drug. Find out more about prior authorization criteria requirements for your plan below.

Drug policies and programs

  • Plan transition drug supply policy
    If you are transitioning to a Journey Rx plan or if you take a drug that has been discontinued or is no longer on our drug list, you may be able to get a transition supply of your drug. Contact customer service with questions.

Appointing a representative and confidential information documents

  • Appoint a representative
    You can choose someone to file grievances, request coverage decisions and redeterminations on your behalf.
  • Authorization to release information
    You can give us permission to give your protected health information (PHI) to a person or organization on your behalf.
  • Confidential communication request
    You can request to have member communications, including claims-related information, mailed to a different address than your permanent address.
  • Our privacy practices
    Learn how information about you may be used and disclosed and how you can get access to this information.