S2893_2030_C
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Last Updated 10/01/2020
Last Updated 10/01/2020
2021 Documents
Enrollment
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Enrollment Form (PDF)
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Sales Brochure (PDF)S2893_2024_M |
Last Updated 10/01/2020 -
Pre-Enrollment Checklist (PDF)S2893_2026_C |
Last Updated 10/01/2020
Plan Documents
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Blue MedicareRx Value Plus Evidence of Coverage (PDF)S2893_2035_C |
Last Updated 10/01/2020 -
Blue MedicareRx Value Plus Annual Notification of Change (PDF)S2893_2036_M |
Last Updated 10/01/2020 -
Blue MedicareRx Premier Evidence of Coverage (PDF)S2893_2035_C |
Last Updated 10/01/2020 -
Blue MedicareRx Premier Annual Notification of Change (PDF)S2893_2036_M |
Last Updated 10/01/2020 -
Summary of Benefits (PDF)S2893_2025_M |
Last Updated 10/01/2020 -
Plan Rating Sheet (PDF)S2893_2027_M |
Last Updated 10/15/2020
News & Tips
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Post ANOC Newsletter (PDF)S2893_2032_M |
Last Updated 10/01/2020 -
Ways to Lower Your Prescription Costs (PDF)S2893_1822_C |
Last Updated 10/01/2020
Formulary / Drug Coverage
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Blue MedicareRx Value Plus Comprehensive Formulary (PDF)S2893_2037_C |
Last Updated 07/01/2021 -
Blue MedicareRx Premier Comprehensive Formulary (PDF)S2893_2037_C |
Last Updated 07/01/2021 -
Blue MedicareRx Prior Authorization Criteria Value Plus (PDF)Last Updated 07/01/2021
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Blue MedicareRx Prior Authorization Criteria Premier (PDF)Last Updated 07/01/2021
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Blue MedicareRx Step Therapy Criteria Value Plus (PDF)Last Updated 07/01/2021
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Blue MedicareRx Step Therapy Criteria Premier (PDF)Last Updated 07/01/2021
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Drug Coverage Determination Request Form (PDF)Last Updated 10/01/2020
Pharmacies / Claims
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Mail Service Order Form / Instructions (PDF)Last Updated 10/01/2020
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Prescription Claim Form (PDF)Last Updated 10/01/2020
Related Documentation
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Appointment of Representative Form (PDF)Last Updated 10/01/2020
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LIS Premium Summary (PDF)S2893_1993_C |
Last Updated 10/01/2020 -
Non-Discrimination Notice (PDF)S2893_1709 |
Last Updated 10/01/2020
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