Plan & Coverage go back
- Summary of Benefits (2019)
Provides a summary of payment and coverage information
- Pre-enrollment checklist (2019)
Tips to help you understand the plan’s benefits and rules
- Evidence of Coverage: contains a full breakdown of payment and coverage information
- Formulary: comprehensive list of all drugs covered by the plan
- Annual Notice of Changes (ANOC) - North Carolina, Pennsylvania and West Virgina (2019)
Details specific changes made to plan at the start of each plan year
- Member Guide: Coverage information for your prescription drug plan
Prescriptions & Payments go back
- Mail order prescription form
Use this form if you would like your drugs to be mailed to you
- Electronic funds transfer form (EFT)
Use this form to set up automatic payments of your monthly bill.
Drug Claims & Alternatives go back
- Prescription drug claim Form - Part D (updated 4/1/19)
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)
Use these forms to request a coverage decision (sometimes called a prior authorization or exception) for a drug in your treatment plan when your health care provider or pharmacist tells you that we will not cover the prescription. Read additional information or use the online form or printable form if this is your first coverage request for a drug.
Use the online form or printable form if you are appealing a previously denied request.
- Quantity limit exception Form
- Step therapy exception Form
- Tiering exception form
- Hospice exception form
- No longer in hospice exception form
- Formulary exception form
- Drug utilization criteria
- Prior authorization criteria
Medication policies and programs go back
- Plan transition policy(2019)
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
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. Download your Personal medication list form.
- 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 (2019)
This form is a list of drugs that are high risk for those eligible for Medicare coverage.
Representative & Confidential Information go back
- 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.
- 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.
- Notice of privacy practices