Plan and coverage documents
- Summary of Benefits (SB)
Provides a summary of prescription drug plan benefits and coverage.
- Pre-enrollment checklist
Tips to help you understand the plan’s benefits and rules.
- Evidence of Coverage (EOC)
Provides details about your prescription drug plan benefits, how to get coverage for prescriptions and important contact information.
- Formulary (drug list)
A list of all the drugs that are covered by the plan.
- Formulary - Value plan (Pennsylvania or West Virginia)* (updated 10/16/19)
- Formulary - Standard plan (updated 10/16/19)
- 2019 to 2020 Notable formulary changes
- Pharmacy directory
Use the pharmacy locator tool to find a pharmacy near you, or have a printed copy mailed to you.
- Enrollment application - Paper
Enter your information on your computer and then print the document or print the form and fill it out by hand. You can also enroll online.
- Plan change form - Paper
Change to a different Basic Blue Rx plan. Enter your information on your computer and then print the document or print the form and fill it out by hand. You can also change your plan online
- Annual Notice of Changes (ANOC)
Summarizes plan changes that will occur in the next plan year. The ANOC is provided to members each year by September 30.
- 2020 Basic Blue Rx member guide
See coverage information for your prescription drug plan.
- Basic Blue Rx Star Rating
View our Star Rating from Medicare. The Star Rating is updated by Medicare each year.
- Mail order prescription form
Complete this form if you would like to receive your prescriptions through our mail order pharmacy service. You can also sign up at Caremark.com.
- Electronic funds transfer (EFT) form
Set up automatic payments for your monthly premium by completing this EFT form. You can also sign up for EFT online.
- Drug claim form for Medicare Part D
Use this form to submit a claim for drugs you purchased that are covered by Medicare Part D. Read more about claims.
- Coverage determinations
Use the forms below to request a coverage decision (sometimes called a prior authorization or an exception) if you take a drug that isn’t covered by our plan. Read more about coverage decisions.
- Coverage redeterminations
If you are appealing a previously denied coverage decision, use the forms below.
- Drug exception forms
If you would like to request a coverage exception, use the applicable form below.
- Step therapy criteria information
Some drugs on our drug list have step therapy requirements that must be met before we will cover the drug. Find out more about step criteria requirements for your plan below.
- Prior authorization criteria information
Some drugs on our drug list have prior authorization requirements that must be met before we will cover the drug. Find out more about prior authorization criteria requirements for your plan below.
- 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.
- Medication therapy management (MTM) program
MTM is a program to help you get the best results from your medication at the lowest cost. Members who meet specific requirements are eligible for this program. If you qualify, we will contact you directly.
- 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.
- 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 & You: The official U.S. government Medicare handbook (updated 10/16/19)
In this handbook you will get a thorough explanation about the Medicare program, when you can enroll, your rights as a beneficiary and much more. Medicare updates the handbook each year.