2025 Documents
Enrollment
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Enrollment Form (PDF)S2893_2419_C |
Last Updated 03/31/2025 -
Sales Brochure (PDF)S2893_2413_M |
Last Updated 10/01/2024 -
Pre-Enrollment Checklist (PDF)S2893_2415_C |
Last Updated 10/01/2024
Plan Documents
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Blue MedicareRx Value Plus Evidence of Coverage (PDF)S2893_2403_C |
Last Updated 06/01/2025 -
Blue MedicareRx Value Plus Annual Notification of Change (PDF)S2893_2402_M |
Last Updated 10/01/2024 -
Blue MedicareRx Premier Evidence of Coverage (PDF)S2893_2403_C |
Last Updated 06/01/2025 -
Blue MedicareRx Premier Annual Notification of Change (PDF)S2893_2402_M |
Last Updated 10/01/2024 -
Summary of Benefits (PDF)S2893_2414_M |
Last Updated 10/01/2024 -
Plan Rating Sheet (PDF)S2893_2490_M |
Last Updated 10/25/2024
News & Tips
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Post ANOC Newsletter (PDF)S2893_2421_C |
Last Updated 10/01/2024 -
Medicare Prescription Payment Plan Fact Sheet (PDF)Last Updated 10/01/2024
Formulary / Drug Coverage
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Blue MedicareRx Value Plus Comprehensive Formulary (PDF)S2893_2404_C |
Last Updated 07/01/2025 -
Blue MedicareRx Premier Comprehensive Formulary (PDF)S2893_2404_C |
Last Updated 07/01/2025 -
Blue MedicareRx Prior Authorization Criteria Value Plus (PDF)Last Updated 07/01/2025
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Blue MedicareRx Prior Authorization Criteria Premier (PDF)Last Updated 07/01/2025
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Blue MedicareRx Step Therapy Criteria Value Plus (PDF)Last Updated 07/01/2025
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Blue MedicareRx Step Therapy Criteria Premier (PDF)Last Updated 07/01/2025
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Drug Coverage Determination Request Form (PDF)Last Updated 10/01/2024
Pharmacies / Claims
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Mail Service Order Form / Instructions (PDF)Last Updated 10/01/2024
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Prescription Claim Form (PDF)Last Updated 10/01/2024
Related Documentation
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Appointment of Representative Form (PDF)Last Updated 11/12/2024
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LIS Premium Summary (PDF)S2893_2438_C |
Last Updated 10/01/2024 -
Non-Discrimination Notice (PDF)S2893_1709 |
Last Updated 10/01/2024 -
Multi-Language Insert (PDF)S2893_2225 |
Last Updated 10/01/2024 -
Individual Electronic Plan Documents (PDF)Last Updated 10/01/2022
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