Erickson Advantage Formulary

Click the link below for the OptumRx formulary (the list of drugs covered under Erickson Advantage). The Erickson Advantage formulary and OptumRx formulary are the same. You will also find the Step Therapy Criteria and Prior Authorization Criteria on OptumRx.

2021 Drug Formulary (external link - opens in new window)

Download and print the Erickson Advantage 2021 Comprehensive Formulary for the Liberty with Drugs, Freedom, Signature, and Guardian Plans:

• English Version (PDF opens in a new window)
• Spanish Version (PDF opens in a new window)

Or view the PDF below.

Download and print the Erickson Advantage 2021 Comprehensive Formulary for the Champion Plan:

• English Version (PDF opens in a new window)
• Spanish Version (PDF opens in a new window)

Or view the PDF below.

Erickson Advantage Drug Management

Click the links below to download your necessary documents.

• 2020 Pharmacy Directory (external link - opens in new window)
• Prescription Drug Transition Process (PDF opens in a new window)
• Medication Therapy Management (PDF opens in a new window)
• Personal Medication Form (PDF opens in a new window)
• Part D Model Coverage Determination Request Form (PDF opens in a new window)
• Part D Model Coverage Redetermination Request Form (PDF opens in a new window)
• Medication Prior Authorization Request Form (PDF opens in a new window)
• Step Therapy Criteria (PDF opens in a new window)
• Appointment of Authorized Representative Form (PDF opens in a new window)
• Privacy Notice under the HIPAA Privacy Rule (external link - opens in a new window)
• Mail Order Pharmacy (PDF opens in a new window)

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

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