Prescription Drug and Pharmacy Information


Drug Information

Formulary Directory

Formulary Guide

Medication Therapy Management (MTM) Medication List

Medication Therapy Management (MTM) Program

Member Part D Claims Form

Pharmacy Directory

Top 100 Drugs

Over-the-Counter (OTC) and Bathroom Safety Devices 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

Privacy Notice (NOPP)

Policies & Procedures

Claims Information


Submit claims to:

Experience Health Claims
P.O. Box 30010
Durham, NC 27702

Member Claim Form

Enrollment Forms


Authorization for Automatic Bank Draft

Enrollment Form

Pre-Enrollment Checklist