2022 Documents
Enrollment
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Enrollment Form (PDF)S2893_2123_C |
Last Updated 10/01/2021 -
Sales Brochure (PDF)S2893_2117_M |
Last Updated 10/01/2021 -
Pre-Enrollment Checklist (PDF)S2893_2119_C |
Last Updated 10/01/2021
Plan Documents
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Blue MedicareRx Value Plus Evidence of Coverage (PDF)S2893_2110_C |
Last Updated 10/01/2021 -
Blue MedicareRx Value Plus Annual Notification of Change (PDF)S2893_2109_M |
Last Updated 10/01/2021 -
Blue MedicareRx Premier Evidence of Coverage (PDF)S2893_2110_C |
Last Updated 10/01/2021 -
Blue MedicareRx Premier Annual Notification of Change (PDF)S2893_2109_M |
Last Updated 10/01/2021 -
Summary of Benefits (PDF)S2893_2118_M |
Last Updated 10/01/2021 -
Plan Rating Sheet (PDF)S2893_2161_M |
Last Updated 10/15/2021
News & Tips
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Post ANOC Newsletter (PDF)S2893_2125_C |
Last Updated 10/01/2021 -
Ways to Lower Your Prescription Costs (PDF)S2893_1822_C |
Last Updated 10/01/2021
Formulary / Drug Coverage
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Blue MedicareRx Value Plus Comprehensive Formulary (PDF)S2893_2111_C |
Last Updated 08/01/2022 -
Blue MedicareRx Premier Comprehensive Formulary (PDF)S2893_2111_C |
Last Updated 08/01/2022 -
Blue MedicareRx Prior Authorization Criteria Value Plus (PDF)Last Updated 08/01/2022
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Blue MedicareRx Prior Authorization Criteria Premier (PDF)Last Updated 08/01/2022
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Blue MedicareRx Step Therapy Criteria Value Plus (PDF)Last Updated 08/01/2022
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Blue MedicareRx Step Therapy Criteria Premier (PDF)Last Updated 08/01/2022
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Drug Coverage Determination Request Form (PDF)Last Updated 10/01/2021
Pharmacies / Claims
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Mail Service Order Form / Instructions (PDF)Last Updated 10/01/2021
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Prescription Claim Form (PDF)Last Updated 10/01/2021
Related Documentation
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Appointment of Representative Form (PDF)Last Updated 08/01/2022
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LIS Premium Summary (PDF)S2893_2145_C |
Last Updated 10/01/2021 -
Non-Discrimination Notice (PDF)S2893_1709 |
Last Updated 10/01/2021
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