Plan documents

Plan and coverage documents

Mail order, automatic payment and claims documents

Coverage decision, redetermination and exception documents

Drug policies and programs

  • Plan transition drug supply policy
    If you are transitioning to a Basic Blue Rx plan or if you take a drug that has been discontinued or is no longer on our drug list, you may be able to get a transition supply of your drug. Contact customer service with questions.
  • Over-the-counter drug and supply coverage
    Some insulin medication and over-the-counter supplies require that you have a prescription before the plan can cover them.
  • High-risk medication alternatives
    See alternatives for some commonly prescribed high-risk medications. Talk with your doctor or pharmacist if you're interested in learning more about alternatives for high-risk medications.

Appointing a representative and confidential information documents

  • Appoint a representative
    You can choose someone to file grievances, request coverage decisions and redeterminations on your behalf.
  • Authorization to release information
    You can give us permission to give your protected health information (PHI) to a person or organization on your behalf.
  • Confidential communication request
    You can request to have member communications, including claims-related information, mailed to a different address than your permanent address.
  • Our privacy practices
    Learn how information about you may be used and disclosed and how you can get access to this information.

Medicare resources

*The Basic Blue Rx Value plan is only available to beneficiaries in Pennsylvania or West Virginia.