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• Mail Service Provider Fax Form AultCare

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• 2025 Premium Managed Formulary v2

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• 163 Medical Rx Claim Form AultCare

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• Designation of Authorized Representitive Form

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• Member Forms

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• 8514_26 AC Aultra Medical Rx Claim Form

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• Generic Incentive Program

  This program assists members with transitioning to a generic equivalent for certain medications when clinically appropriate. An incentive may reduce member cost share. This cost-share adjustment is based on brand name manufacturer assistance programs. Please call AultCare Customer Service at 330-363-6360 or 1-800-344-8858 (TTY 711) for any questions regarding this…

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• Marketplace Managed Formulary AultCare

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• Healthcare Reform Copay Waiver Request Enrollment Form

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• 2024 Marketpalce Managed Formulary

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