Request a formulary  
 Complete the form below to have a 2022 paper formulary mailed to you. Please expect 10 business days to arrive.  

 
 

Consider the following when making the formulary selection:

  • 2022 Prescription Drug Formulary: All plans except Choice + Rx, Enrich + Rx, Extra + Rx, and Latitude + Rx
    Formulary for the following plans: Bridge 1 + Rx (HMO-POS), Bridge 2 + Rx (HMO-POS), Compass + Rx (HMO-POS), Cottonwood + Rx (HMO-POS), Harbor + Rx (HMO), Pine + Rx (HMO), Prime + Rx (HMO), Summit + Rx (HMO-POS), and Timber + Rx (HMO)
  • 2022 Prescription Drug Formulary: Choice, Extra and Latitude plans only
    Formulary for Choice + Rx 001 (HMO-POS), Choice + Rx 002 (HMO-POS), Extra + Rx 001 (HMO), Extra + Rx 002 (HMO), Extra Part B Only + Rx (HMO), and Latitude + Rx (HMO-POS)

  • 2022 Prescription Drug Formulary: Enrich plan
    Formulary for our Enrich + Rx (HMO) plan
  • 2022 Prescription Drug Formulary: Dual Plus plan
    Formulary for our Dual Plus (HMO D-SNP) plan
  • 2022 Prescription Drug Formulary: Align Group plan
    Formulary for Align + Rx 10/50/1000 (HMO), Align + Rx 15/30 (HMO)

  • 2022 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.

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