I am already enrolled - Part D

Forms and Applications

The following materials can be downloaded and printed using Adobe Acrobat Reader, which is available free. Additional forms and information will be added as they become available.

Name	Links
Application	1.7MB 4 pgs.
Appointment of Representative	92KB, 2 pgs.
Claim Form	62KB, 2 pgs.
Coordination of Benefits Survey	1.5KB, 4 pgs.
Coverage Determination Form	89KB, 2 pgs.
Easy Pay Brochure	1.3MB, 4 pgs.
Evidence of Coverage (Blue Rx Standard Plan)	1.2MB, 68 pgs.
Evidence of Coverage (Blue Rx Enhanced Plan)	604KB, 68 pgs.
Informational Brochure	946KB, 13 pgs.
Pharmacy Directory	274KB, 78 pgs.
Privacy Practices	194KB, 4 pgs.
Summary of Benefits	186KB, 12 pgs.
Transition Notice	64KB, 2 pgs.
Annual Notice of Change - Blue Rx Standard	266KB, 12 pgs.
Annual Notice of Change - Blue Rx Enhanced	280KB, 12 pgs.

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Health and Wellness Information

Foods That Help You
LOSE WEIGHT

Low-calorie, high-fiber foods such as fruits and vegetables fill you up but don't add that much to your daily calorie total.

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Options
Discount Program

Options Discount Program takes you in healthy directions by opening the door to discounts on a broad range of alternative therapies and wellness services.

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