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_TX_PDPSB14 Accepted 10012013
Summary of Benefits en Español  
Y0096_BEN_TX_PDPSB14SPA
Drug List - Basic 
Y0096_MRK_TMP_PDFRMCV14a Approved 08132013_TX BASIC
Drug List - Basic Plan en Español 
Y0096_MRK_TMP_PDFRMLR14aSPA_TX_Basic
Drug List - Value and Plus  
Y0096_MRK_TMP_PDFRMCV14a Approved 08132013_TX Value_Plus
Drug List - Value and Plus Plan en Español 
Y0096_MRK_TMP_PDFRMLR14aSPA_TX_Plus
Pharmacy Directory  
Y0096_BEN_TMP_PDPHDR14 Accepted 082013_TX
Pharmacy Directory en Español  
Y0096_BEN_TMP_PDPHDR14SPA Accepted 082013_TX
Evidence of Coverage - Basic
Y0096_BEN_ TX_EOCBASIC2014 Accepted 08302013
Evidence of Coverage: Basic Plan en Español
Y0096_BEN_TMP_PDPEOCCVR13SPA Approved 08222013
Evidence of Coverage -Value
Y0096_BEN_ TX_ANOCEOCVALUE2014 Accepted 082620
Evidence of Coverage: Value Plan en Español
Y0096_BEN_TMP_PDPEOCCVR13SPA Approved 08222013
Evidence of Coverage - Plus  
Y0096_BEN_TX_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_TX_BEN_BNFTSMRY13 Accepted 09162012
Summary of Benefits en Español  
S5715_TX_BEN_BNFTSMRY13SPA Accepted 09162012
Drug List  
S5715_MRK_TX_TMP_FRMLRY13a
Drug list en Español  
S5715_MRK_TX_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_TX_EOCVALUE2013
Evidence of Coverage: Value Plan en Español
S5715_BEN_TX_ANOCEOCVALUE2013SPA
Evidence of Coverage Plus Plan  
S5715_BEN_TX_ANOCEOCPLS2013
Evidence of Coverage: Plus Plan en Español  
S5715_BEN_TX_ANOCEOCPLS2013SPA