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.


Forms and Applications for Part D Plans
Name Links
Application
Appointment of Representative
Authorization of Information Release
Claim Form
Coordination of Benefits Survey
Coverage Determination Form
Designation of Personal Representative
Easy Pay Brochure
Annual Notice of Change/Evidence of Coverage (Blue Rx Standard (PDP) Plan)
Annual Notice of Change/Evidence of Coverage (Blue Rx Enhanced (PDP) Plan)
Pharmacy Directory
Plan Change Form
Pre-Sale Kit
Privacy Practices
Revocation of Authorization or Designation of Personal Representative
Summary of Benefits
Transition Notice

Send Me Information


Send me an information kit about the Blue Rx (PDP) Plans.


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