2024 Documents
Enrollment
-
Enrollment Form (PDF)S2893_2317_C |
Last Updated 03/01/2024 -
Sales Brochure (PDF)S2893_2311_M |
Last Updated 10/01/2023 -
Pre-Enrollment Checklist (PDF)S2893_2313_M |
Last Updated 10/01/2023
Plan Documents
-
Blue MedicareRx Value Plus Evidence of Coverage (PDF)S2893_2304_C |
Last Updated 02/06/2024 -
Blue MedicareRx Value Plus Annual Notification of Change (PDF)S2893_2303_M |
Last Updated 02/06/2024 -
Blue MedicareRx Premier Evidence of Coverage (PDF)S2893_2304_C |
Last Updated 02/06/2024 -
Blue MedicareRx Premier Annual Notification of Change (PDF)S2893_2303_M |
Last Updated 02/06/2024 -
Summary of Benefits (PDF)S2893_2312_M |
Last Updated 10/01/2023 -
Plan Rating Sheet (PDF)S2893_2360_M |
Last Updated 10/21/2023
News & Tips
-
Post ANOC Newsletter (PDF)S2893_2319_C |
Last Updated 10/01/2023
Formulary / Drug Coverage
-
Blue MedicareRx Value Plus Comprehensive Formulary (PDF)S2893_2305_C |
Last Updated 04/01/2024 -
Blue MedicareRx Premier Comprehensive Formulary (PDF)S2893_2305_C |
Last Updated 04/01/2024 -
Blue MedicareRx Prior Authorization Criteria Value Plus (PDF)Last Updated 04/15/2024
-
Blue MedicareRx Prior Authorization Criteria Premier (PDF)Last Updated 04/15/2024
-
Blue MedicareRx Step Therapy Criteria Value Plus (PDF)Last Updated 04/01/2024
-
Blue MedicareRx Step Therapy Criteria Premier (PDF)Last Updated 04/01/2024
-
Drug Coverage Determination Request Form (PDF)Last Updated 10/01/2023
Pharmacies / Claims
-
Mail Service Order Form / Instructions (PDF)Last Updated 10/01/2023
-
Prescription Claim Form (PDF)Last Updated 10/01/2023
Related Documentation
-
Appointment of Representative Form (PDF)Last Updated 10/01/2023
-
LIS Premium Summary (PDF)S2893_2347_C |
Last Updated 10/01/2023 -
Non-Discrimination Notice (PDF)S2893_1709 |
Last Updated 10/01/2022 -
Multi-Language Insert (PDF)S2893_2225 |
Last Updated 10/01/2023 -
Individual Electronic Plan Documents (PDF)Last Updated 10/01/2022
Go paperless!
Sign up for paperless Explanation of Benefits (EOB) to stop receiving yours by mail.
Sign up