Plan & Coverage
- Summary of Benefits
Provides a summary of payment and coverage information - Evidence of Coverage
Contains a full breakdown of payment and coverage information - Formularies
Comprehensive list of all drugs covered by each plan- Blue MedicareRx Formulary (updated 3/31/21)
- Pharmacy Search & Directories
- Order a free print copy sent by mail.
- Annual Notice of Changes
Details specific changes made to plan at the start of each plan year - Enrollment Forms
Prescriptions & Payments
- Mail Order Prescription Form
Use this form if you would like your drugs to be mailed to you. - Electronic Funds Transfer (EFT)
Use this form to set up automatic payments of your monthly bill.
Drug Claims & Alternatives
- Prescription Drug Claim Form - Part D
Use this form to submit a claim for purchased drugs covered by Medicare Part D. Frequently asked questions on how to use the form. - Coverage Determinations (Prior Authorization or Exceptions)
Use these forms to request a coverage decision (sometimes called a prior authorization or exception) for a drug if your health care provider or pharmacist tells you that we will not cover a prescription drug that is in your treatment plan. For more information, visit the Coverage Determination page.- Coverage Determination: Use the online form or printable form to make a coverage determination request for a drug.
- Redetermination: Use the online form or call 877-403-6038 to request an appeal for a previously denied request.
- Drug Utilization Criteria
- Prior Authorization Criteria
- Prior Authorization Criteria for Blue MedicareRx (updated 4/1/21)
- Plan Transition Policy
This policy details how to get coverage when transitioning to a Blue MedicareRx plan. Contact customer service with any questions. - Medication Therapy Management Program
The goal of this program is to help you get the best results from your medication at the lowest possible price. Contact customer service with any questions. - Covered Over-the-Counter Insulin and Insulin Administration
Certain Insulin medications and over-the-counter supplies require a prescription to be covered.
Representative & Confidential Information
- Appointing a Representative - You may choose someone to act on your behalf in filing a grievance and requesting a coverage determination or redetermination.
- Authorization to Release Information - Use this form to provide Protected Health Information (PHI) to a person or organization on your behalf.
- Notice of Privacy Practices
General Information
- Medicare & You, a comprehensive guide (updated 10/16/19)
Blue MedicareRx Formularios Disponibles en Español
- Autorización para divulgar información
- Formulario de inscripcion: Blue MedicareRx
- Evidencia de cobertura - Essential (EOC)
- Evidencia de cobertura - Enhanced (EOC)
- Evidencia de cobertura - Value (EOC)
- Directorio de farmacias (updated 3/19/2021)
- Calificaciones por estrellas Medicare
- Aviso de privacidad
- Nombramiento de un Representante
- Resumen de beneficios
- Lista de verificación de preinscripción
- LIS Summary
- Aviso anual de cabios para - Enhanced (ANOC)
- Aviso anual de cabios para - Value (ANOC)
- Aviso anual de cabios para - Essential (ANOC)
- Formulario de pedido por correo de medicamento recetado
- Formulario
- Parte D de Medicare Formulario de Reclamación
- Formulario de decisión de cobertura para imprimir
- Formulario de redeterminación para imprimir
- Formulario de excepción de límite de cantidad
- Formulario de excepción de terapia en etapas
- Formulario de excepción de niveles
- Formulario de excepción de la lista de medicamentos
- Medicare Y Usted
- Transferencia Electrónica de Fondos
- Formulario de cambio de plan
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