Annual Notice of Pharmacy Resources for Prescribers 

Our medication and pharmacy information is updated as changes occur. Please visit our pharmacy website at least quarterly to view the most recent information.

For the 2026 year, a list of retail pharmacy medications that require authorization or are excluded, and the Preferred Drug List (PDL)/Formulary for retail/specialty pharmacy medications is available online. “Bookmark” the sites below for convenient reference.

MEDICAL PHARMACY MEDICATIONS 

• View the current list of medical pharmacy services and products requiring prior authorization or that are excluded by visiting Search Codes Requiring Authorization.
• For injections, infusions, and other medications administered in a clinical setting, complete the appropriate Prior Authorization Form: Online Submission Form or Fax Form.
• Remember to attach supporting documentation as indicated. Failure to submit clinical documentation supporting this request will result in dismissal of the request.

RETAIL PHARMACY MEDICATIONS 

For retail and specialty pharmacy medications, refer to the Preferred Drug List (PDL)/Formulary for covered medications, drug tiers, prescribing limits, generic substitution, therapeutic interchange, step therapy, or prior authorization requirements. Pick the formulary that matches your member’s benefit plan.

Retail Pharmacy Prior Authorization (PA) Process: PA requests may be submitted online or by fax.

• Online: Visit our Pharmacy Benefit Manager (PBM), RealRx Home Dashboard. Go to “Request Prior Authorization” and click “Get Started.”
• Fax: Complete the appropriate Pharmacy Prior Authorization Form for the specific medication or category for your request, and the form specific to the member’s benefit plan. If there is not a specific form for the requested medication, use the General Pharmacy Prior Authorization Form. Fax the completed form, along with all supporting documentation, to 385-425-4052.

If you are requesting a drug that is not on the health plan formulary, complete the Pharmacy Formulary Exception Request Form that corresponds to the member’s benefit plan. Include supporting clinical documentation showing a medical reason that a formulary alternative would not be effective for the member.

For upcoming changes to the formulary coverage and edits, notices are placed on the website for review. View the most current “Formulary Change Notices” on the Pharmacy Formularies web page, just below the Searchable Directories.

If you have questions regarding a prior authorization or need assistance completing the form, please call 385-425-5094.

QUESTIONS? 

Medical Pharmacy Medications — call our Customer Service team at 877-358-8797

Retail Pharmacy Medications — call our Pharmacy Customer Service team at 855-864-1404