Formulary & Forms

Erickson Advantage Formulary

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To see the list of drugs covered under Erickson Advantage you may access the PDFs below or visit the Optum Rx formulary website.

Liberty, Freedom, and Signature Plans:

English (PDF) | Spanish (PDF) | Optum Rx Online

Champion Plan:

English (PDF) | Spanish (PDF) | Optum Rx Online

Guardian Plan:

English (PDF) | Spanish (PDF) | Optum Rx Online

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

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Step Therapy and Prior Authorization

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Freedom, Liberty, Signature, and Guardian Plans

  • Prior Authorization (PDF)
  • Step Therapy Criteria (PDF)

Champion Plan

  • Prior Authorization (PDF)
  • Step Therapy Criteria (PDF)

Forms

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  • Prescription Drug Transition Process (PDF)
  • Medication Therapy Management (PDF)
  • Personal Medication Form (PDF)
  • Part D Model Coverage Determination Request Form (PDF)
  • Part D Model Coverage Redetermination Request Form (PDF)
  • Mail Order Pharmacy (PDF)
  • Alternative Covered Drugs - English (PDF) | Spanish (PDF)
  • Medication Prior Authorization Request Form (PDF)

External Links

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