Erickson Advantage Formulary
To see the list of drugs covered under Erickson Advantage you may access the PDFs below or visit the Optum Rx formulary website. You can also view the prior authorization and step therapy criteria documents on the Optum Rx Online Formulary Website.
For the Champion Plan:
English PDF | Spanish PDF | Optum Rx Online Formulary Website
For the Guardian Plan:
English PDF | Spanish PDF | Optum Rx Online Formulary Website
For the Liberty with Drugs, Freedom, and Signature Plans:
English PDF | Spanish PDF | Optum Rx Online Formulary Website
Erickson Advantage Drug Management
Click the links below to download your necessary documents.
- 2023 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)
- 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.