Prescription Drug and Pharmacy Information


Formulary Directory

Medication Therapy Management (MTM) Medication List

Medication Therapy Management (MTM) Program

Member Part D Claims Form

Pharmacy Directory

Over-the-Counter (OTC) Catalog

Request for Medicare Prescription Drug Determination

Other important programs, forms and policies


Appointment of Representative (AOR) Form

Diabetes Prevention Program (MDPP)

Important Legal Information

LIS Premium Summary Chart

Non-Discrimination Policy

PHI Authorization Request Form

Claims Information


Submit claims to:

Experience Health Claims
PO Box 17509
Winston-Salem, NC 27116-7509

Member Claim Form

Enrollment Forms


Authorization for Automatic Bank Draft

Pre-Enrollment Checklist

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