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 Coveragepage top | go back
Contains a full breakdown of payment and coverage information
- Formulary page top | go back
Comprehensive list of all drugs covered by the plan
- Pharmacy directory 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 Formpage 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.
- Coverage Determination: Use the online form or printable version if this is your first coverage request for a drug and you want to submit it online.
- Redetermination: Use the online form or printable version if you are appealing a previously denied request and you want to submit it online.
- Drug Utilization Criteria page top | go back
- Prior Authorization Criteria page top | go back
- Plan Transition Policypage top | go back
This policy details how to get coverage when transitioning to a Basic Blue Rx 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
Certain Insulin medications and over-the-counter supplies require a prescription to be covered.
- High Risk Medications - Safer Drug Choices - This form is a list of drugs that are high risk for those eligible for Medicare coverage
Representative & Confidential InformationRepresentative & Confidential Informationpage top | go back
- Appointing a Representative - You may choose someone to act on your behalf. 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 Basic Blue 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.
- Agent of Record Exception Form - Use this form to request a new Agent if a situation arises where you cannot, in good faith, continue business relations with your original Agent. Completing this form does not guarantee a new Agent assignment will be made.
- Notice of Privacy Practices