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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 | |
| Claim Form | |
| Coordination of Benefits Survey | |
| Coverage Determination Form | |
| Easy Pay Brochure | |
| Evidence of Coverage (Blue Rx Standard Plan) |
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| Evidence of Coverage (Blue Rx Enhanced Plan) |
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| Informational Brochure | |
| Pharmacy Directory | |
| Privacy Practices | |
| Summary of Benefits | |
| Transition Notice | |
| Annual Notice of Change - Blue Rx Standard |
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| Annual Notice of Change - Blue Rx Enhanced |
Send me an information kit about the Blue Rx Plans.
Viewing & printing this form requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.