Forms and Alternate Formats


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Use the forms below to manage your Blue Cross MedicareRxSM coverage.

Appointment of Representative 
Authorization to Disclose Protected Health Information 
Automated Premium Payment (ACH) Form 
Prescription Drug Mail-Order Form 
Prescription Drug Claim Form 
Prior Authorization 
Request for Medicare Prescription Drug Coverage Determination Form 
Request for Redetermination of Medicare Prescription Drug Denial Form 
Physician Fax Form 
File a Grievance  (Please select your health plan and health plan type for information about filing a grievance.)
Step Therapy Form 

en Español



Alternate formats for these materials, including Spanish translations, may be available. Please contact our Product Specialists for additional information.

Este material está disponible en otros formatos, incluida la traducción al Español. Contacte nuestro numero de Servicio al Cliente para obtener información adicional.

Materials in English - 2014 Materiales en Español - 2014
Summary of Benefits  
Y0096_BEN_OK_PDPSB14 Accepted
Summary of Benefits en Español
Y0096_BEN_OK_PDPSB14SPA
Drug List - Basic Plan  
Y0096_MRK_TMP_PDFRMLR14a Accepted 10012013
Drug List - Basic Plan en Español 
Y0096_MRK_TMP_PDFRMLR14aSPA_OK_Basic
Drug List - Value and Plus Plans  
Y0096_MRK_TMP_PDFRMCV14a Approved 08132013
Drug List - Value and Plus Plan en Español 
Y0096_MRK_TMP_PDFRMLR14aSPA_OK_Plus
Pharmacy Directory  
Y0096_MRK_TMP_RXPHCVR14a Approved 08132013
Pharmacy Directory en Español  
Y0096_MRK_TMP_RXPHCVR14aSPA OK
Evidence of Coverage: Basic Plan
Y0096_BEN_ OK_EOCBASIC2014 Accepted 08302013
Evidence of Coverage: Basic Plan en Español
Y0096_BEN_TMP_PDPEOCCVR13SPA Approved 08222013
Evidence of Coverage: Value Plan
Y0096_BEN_ OK_ANOCEOCVALUE2014 Accepted 08232013
Evidence of Coverage: Value Plan en Español
Y0096_BEN_TMP_PDPEOCCVR13SPA Approved 08222013
Evidence of Coverage Plus Plan  
Y0096_BEN_ OK_ANOCEOCPLUS2014 Accepted 08232013
Evidence of Coverage: Plus Plan en Español
Y0096_BEN_TMP_PDPEOCCVR13SPA Approved 08222013


Materials in English - 2013 Materiales en Español - 2013
Summary of Benefits  
S5715_OK_BEN_BNFTSMRY13
Summary of Benefits en Español  
S5715_OK_BEN_BNFTSMRY13SPA Accepted 09152012
Drug List  
S5715_MRK_OK_TMP_FRMLRY13a
Drug list en Español  
S5715_MRK_OK_TMP_FRMLRY13aSPA
Pharmacy Directory  
S5715_BEN_TMP_RXDRCTRY13 Accepted 10012012
Pharmacy Directory en Español 
S5715_BEN_TMP_RXDRCTRY13SPA Accepted 10012012
Evidence of Coverage: Value Plan
S5715_BEN_OK_EOCVALUE2013
Evidence of Coverage: Value Plan en Español
S5715_BEN_OK_ANOCEOCVALUE2013SPA
Evidence of Coverage Plus Plan  
S5715_BEN_OK_ANOCEOCPLS2013
Evidence of Coverage: Plus Plan en Español
S5715_BEN_OK_ANOCEOCPLUS2013SPA