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
Champion Plan
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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