Forms and Alternate Formats

Use the forms below to manage your Blue MedicareRx^SM 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
Appeal Instructions
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	Materiales en Español
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 Accepted 09282012	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