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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• Medication Therapy Management (PDF)
• Personal Medication Form (PDF)

External Links

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• 2024 Pharmacy Directory
• Prescription Drug Transition Process
• Medicare Advantage (Part C) coverage decisions, appeals, and grievances
• Prescription drug coverage determinations, appeals, and grievances
• Appointment of Authorized Representative Form
• UnitedHealthcare Medicare Advantage Policies and Guidelines