Request a formulary

2024 Medicare formulary request

Request a formulary

Complete the form below to have a 2024 paper formulary mailed to you. Please expect 10 business days to arrive.

Consider the following when making the formulary selection:

2024 Prescription Drug Formulary: All Individual plans except Choice + Rx, Dual Plus + Rx, and Sycamore + Rx
Formulary for the following plans: Bridge + Rx (HMO-POS), Cottonwood + Rx (HMO-POS), Extra + Rx (HMO), Pine + Rx (HMO), Prime + Rx (HMO), and Timber + Rx (HMO).

2024 Prescription Drug Formulary: Choice + Rx
Formulary for Choice + Rx (HMO-POS)

2024 Prescription Drug Formulary: Sycamore + Rx
Formulary for Sycamore + Rx (HMO)

2024 Prescription Drug Formulary: Dual Plus plan
Formulary for our Dual Plus (HMO D-SNP) plan

2024 Prescription Drug Formulary: Align Group plan
Formulary for Align + Rx 10/50/1000 (HMO), Align + Rx 15/30 (HMO)
2024 Prescription Drug Formulary: Discover Group plan and Explore Group plan
Formulary for Align-Discover + Rx (HMO), 804 Align-Explore + Rx (HMO), and 805 Discover + Rx (HMO-POS), 805 Explore + Rx (HMO-POS)

The formulary may change at any time. You will receive notice when necessary.

Select if you would like to receive your hardcopy annually each year before the Annual Enrollment Period begins or just this one time:
Your selection will be documented on your member account. Please contact customer service to make any changes. Non-member requests will be completed as a one-time request.*

	Annual request
	One-time request

	First and last name:*

	Mailing address:* Please include street address, city, state and ZIP code.

	Select which formulary version you would like sent to you:*

	Phone number:

	Email address: