Documents for BCBSAZ Medicare Rx (PDP) Members in Arizona

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
- Value - Evidence of Coverage (EOC)
- Enhanced - Evidence of Coverage (EOC)
Formularies
Comprehensive list of all drugs covered by each plan
- Blue MedicareRx Formulary (updated 1/5/22)
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 to Value Annual Notice of Changes (ANOC) (For 2021 Essential members whose plan was combined with Value for 2022)
Enrollment Forms
- Blue MedicareRx Enrollment Form
- Blue MedicareRx Change Form

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)

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 1/12/22)
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

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

File or Link