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 |
|
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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