Plan & Coverage

• Summary of Benefits
  Provides a summary of payment and coverage information
  • Summary of Benefits 
• Evidence of Coverage
  Contains a full breakdown of payment and coverage information
  • Essential - Evidence of Coverage (EOC) 
  • Value - Evidence of Coverage (EOC) 
  • Enhanced - Evidence of Coverage (EOC) 
• Formularies
  Comprehensive list of all drugs covered by each plan
  • Blue MedicareRx Formulary (updated 9/28/21)
• Pharmacy Search & Directories
  • Online Pharmacy Search
  • 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
  • Value Annual Notice of Changes (ANOC) 
  • Enhanced Annual Notice of Changes (ANOC) 
  • Essential Annual Notice of Changes (ANOC) 
• Enrollment Forms
  • Blue MedicareRx Enrollment Form 
  • Blue MedicareRx Change Form 

Prescriptions & Payments

• Mail Order Prescription Form
  Use this form if you would like your drugs to be mailed to you.
  • Mail Order Prescription Form
• Electronic Funds Transfer (EFT)
  Use this form to set up automatic payments of your monthly bill.
  • Electronic Funds Transfer form (EFT)

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.
  • Medicare Prescription Drug Claim 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
  • Step Therapy Criteria for Blue MedicareRx  
• Prior Authorization Criteria
  • Prior Authorization Criteria for Blue MedicareRx (updated 9/1/21)
• Plan Transition Policy
  This policy details how to get coverage when transitioning to a Blue MedicareRx plan. Contact customer service with any questions.
  • Medicare Transition Policy
• 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.
  • Medication Therapy Management Program (MTM) 
  • Personal Medication List Form
• 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 9/10/2021)
• 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
• 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