On this page:
Plan & Coverage || Enrollment Forms || Prescriptions & Payments || Drug Claims & Alternatives || Representive & Confidential Info. || General Information || Formularios Disponibles en Español
- Summary of Benefits page top | go back
Provides a summary of payment and coverage information
- Evidence of Coverage page top | go back
Contains a full breakdown of payment and coverage information
- Formularies page top | go back
Comprehensive list of all drugs covered by each plan
- Pharmacy directories page top | go back
- Annual Notice of Changes page top | go back
Details specific changes made to plan at the start of each plan year
- Enrollment Formspage top | go back
- Mail Order Prescription Form page top | go back
Use this form if you would like your drugs to be mailed to you.
- Electronic Funds Transfer (EFT) page top | go back
Use this form to set up automatic payments of your monthly bill.
- Prescription Drug Claim Form - Part D page top | go back
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) page top | go back
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: more information.
- Quantity Limit Exception Fax Form
- Step Therapy Exception Fax Form
- Tiering Exception Fax Form
- Hospice Exception Form
- No Longer in Hospice Exception Form
- Formulary Exception Fax Exception
- Drug Utilization Criteria page top | go back
- Prior Authorization Criteria page top | go back
- Plan Transition Policy page top | go back
This policy details how to get coverage when transitioning to a Blue MedicareRx plan. Contact customer service with any questions.
- Medication Therapy Management Program page top | go back
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 (2017)
Certain Insulin medications and over-the-counter supplies require a prescription to be covered.
- High Risk Medications - Safer Drug Choices (2017)
This form is a list of drugs that are high risk for those eligible for Medicare coverage
- Appointing a Representative - You may choose someone to act on your behalf in filing a grievance, in requesting a coverage determination, and in requesting a redetermination. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.
- Authorization to Release Information - Use this form to provide Protected Health Information (PHI) to a person or organization on your behalf.
- Confidential Communication Request - Complete this form if you want MedicareBlue Rx (PDP) to use a different address when sending member communications including claim related material to you. There may be others involved in your healthcare you may want to contact to make a similar request.
- Notice of Privacy Practices
- Autorización para divulgar información
- Formulario de inscripcion: Blue MedicareRx (2017)
- Evidencia de cobertura - Enhanced (EOC) (2017)
- Evidencia de cobertura - Value (EOC) (2017)
- Directorio de farmacias (2017)
- Calificaciones por estrellas Medicare
- Aviso de privacidad
- Nombramiento de un Representante
- Resumen de beneficios (2017)
- LIS Summary (2017)
- Aviso anual de cabios para - Enhanced (ANOC) (2017)
- Aviso anual de cabios para - Value (ANOC) (2017)
- Formulario de pedido por correo de medicamento recetado
- Formulario - Value (2017)
- Formulario - Enhanced (2017)
- Parte D de Medicare Formulario de Reclamación
- Parte D de Medicare Formulario de Reclamación (2014)
- El Programa de la Terapia de Medicamentos de la Parte D de Medicare