Medication Formularies

Medicare Formulary

• For Medicare Information, click here

Grandfathered Commercial Plans

Plan Codes:

| B62 | G01 | G20 | H01 | H23 | 321 | 615 | 621 | 622 | 625 | 632 | 640 | 651 | 652 | 660 | 683 | 684 |

• 2025 Prescription Drug Formulary (PDF) | Drug Search | Prior Authorization Criteria
• Medical Pharmacy Formulary (PDF) | Drug Search| Prior Authorization Criteria
• FHCP $0 Drug List

Non-Grandfathered Commercial Plans

• 2025 Prescription Drug Formulary (PDF) | Drug Search | Prior Authorization Criteria
• Medical Pharmacy Formulary (PDF) | Drug Search| Prior Authorization Criteria
• FHCP $0 Drug List

Federal Exchange Plans

• 2025 Prescription Drug Formulary (PDF) | Drug Search | Prior Authorization Criteria
• 2025 Prescription Drug Formulary 1340 Plan (PDF) | Drug Search | Prior Authorization Criteria
• Medical Pharmacy Formulary (PDF) | Drug Search | Prior Authorization Criteria
• FHCP $0 Drug List

Federal Exchange Standard Plans

Plan Codes:

| KI1 | QI1 | QI2 | U37 | KJ1 | QJ1 | QJ2 | U38 | QJ3 | QJ4 | QJ5 | KK1 | QK1 | QK2 | U39 | KI2 | QI3 | QI4 | U41 | KJ2 | QJ6 | QJ7 | U42 | QJ8 | QJ9 | QJ0 | KK2 | QK3 | QK4 | U43 | KL2 | QL3 | QL4 | U44 |

• 2025 Prescription Drug Formulary (PDF) | Drug Search | Prior Authorization Criteria
• Medical Pharmacy Formulary (PDF) | Drug Search | Prior Authorization Criteria
• FHCP $0 Drug List

Prior Authorization Form

• FHCP Prior Authorization Medication Form (must be completed by physician)
• FHCP Prior Authorization Medication Policy and Drug List

Formulary Exceptions

• Formulary Exception Request Form