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

Prominence Standard Plan Formularies

• 2024 Standard Plans Formularies
• 2024 Standard Plans Formularies (Spanish)

Prominence Dual & Extra Help Plan Formularies

• 2024 Florida Dual Plan Formulary
• 2024 Florida Dual Plan Formulary (Spanish)
• 2024 Prominence Dual & Extra Help Plan Formulary
• 2024 Prominence Dual & Extra Help Plan Formulary (Spanish)
• 2024 Texas Dual Plan Formulary
• 2024 Texas Dual Plan Formulary (Spanish)

Prominence Heart Plan Formularies

• 2024 Heart Plan Formulary
• 2024 Heart Plan Formulary (Spanish)

Resources

• 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

• 2024 Step Therapy Criteria
• 2024 Prior Authorization
• Part D Prescription Drug Transition Process
• Request for Medicare Prescription Drug Coverage Determination
• Request for Medicare Prescription Drug Coverage Redetermination
• Personal Medication List
• Formulary Change Notice — none at this time
• Prescription Reimbursement Claim Form
• Prescription Reimbursement Claim Form (Spanish)
• Medication Order Form
• Medication Order Form (Spanish)

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Last update 4/3/2024