2012 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 |
|---|---|
Annual Notice of Change/Evidence of Coverage (BlueRx Standard (PDP) Plan) |
|
Annual Notice of Change/Evidence of Coverage (BlueRx Enhanced (PDP) Plan) |
|
Application |
|
Appointment of Representative |
|
Authorization of Information Release |
|
Claim Form |
|
Comprehensive Formulary (Drug List) |
|
Coverage Determination Form (BlueRx) |
|
Coverage Determination, Exception, Prior Authorization or Appeals for Members – Online Secure Form |
|
Designation of Personal Representative |
|
Easy Pay Brochure |
|
Pharmacy Directory |
|
Plan Change Form |
|
Privacy Practices |
|
Request for Redetermination (Appeal) Form |
|
Revocation of Authorization or Designation of Personal Representative |
|
Summary of Benefits |
|
Transition Notice |
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