Prescription Drug Formulary, Forms and Resources
The following information, forms and resources will assist you in understanding and managing your Part D prescription drug coverage.
Prescription Drug Formularies
2026
Formulary #1
Applies to the following plans:
- Plus (HMO) – Northern Nevada, Washoe, Palm Beach, North Texas, South Texas
- Extra Help (HMO) – Northern Nevada, Washoe, Palm Beach, North Texas, South Texas
- Dual (HMO DSNP) – Northern Nevada, Washoe, Palm Beach, North Texas, South Texas
- Giveback (HMO) – Washoe, Palm Beach, North Texas, South Texas
- Beyond (HMO) – North Texas, South Texas
Formulary #2
Applies to the following plans:
- Dual (HMO DSNP) – Palm Beach
Formulary #4
Applies to the following plans:
- Diabetes and Heart Giveback (HMO CSNP) – Washoe
Formulary #5
Applies to the following plans:
- Diabetes and Heart Giveback (HMO) – North Texas, South Texas, Palm Beach
- Diabetes and Heart Care Plus (HMO) – South Texas
Formulario de Prominence N.°1
Formulario 2026 (Lista de medicamentos cubiertos):
- Plus (HMO) – Northern Nevada, Washoe, Palm Beach, North Texas, South Texas
- Extra Help (HMO) – Northern Nevada, Washoe, Palm Beach, North Texas, South Texas
- Dual (HMO DSNP) – Northern Nevada, Washoe, Palm Beach, North Texas, South Texas
- Giveback (HMO) – Washoe, Palm Beach, North Texas, South Texas
- Beyond (HMO) – North Texas, South Texas
Formulario de Prominence N.°2
Formulario 2026 (Lista de medicamentos cubiertos):
- Dual (HMO DSNP) – Palm Beach
Formulario de Prominence N.°4
Formulario 2026 (Lista de medicamentos cubiertos):
- Diabetes and Heart Giveback (HMO CSNP) – Washoe
Formulario de Prominence N.°5
Formulario 2026 (Lista de medicamentos cubiertos):
- Diabetes and Heart Giveback (HMO) – North Texas, South Texas, Palm Beach
- Diabetes and Heart Care Plus (HMO) – South Texas
Resources
- Pharmacy Direct Member Reimbursement Form (English) →
- Pharmacy Direct Member Reimbursement Form (Spanish) →
- Medication Therapy Management (MTM) Program →
- Part D Appeal Rights (Request for Redetermination of Medicare Prescription Drug Denial) →
- Prescription Drug Extra Help Table →
- Medicare Best Available Evidence Policy
- Savings on Insulin →
Downloadable Forms
Enroll in a Prominence Health Plan Medicare Advantage plan.
The comprehensive provider network offers members excellent access to quality medical services.
