For Providers

Forms

This page links to the various forms you'll need to conduct business regarding MedicareBlue PPO and MedicareBlue Rx.

MedicareBlue Rx

MedicareBlue PPO

Formulary Exception Form (PDF)
Pharmancy Prior Authorization Form (PDF)
Quantity Limit Forms (PDF)
Step Therapy Forms (PDF)
Admission Notification (PDF)
Durable Medical Equipment and Medical Supply Prior Authorization (PDF)
Durable Medical Equipment Upgrade (PDF)
Medical Prior Authorization Request (PDF)
Provider Appeal Form (PDF)
Notice of Denial of Medical Coverage (PDF)
Notice of Medicare Non-Coverage (PDF)
Detailed Explanation of Non-Coverage (PDF)

May 16, 2008

Important Information

This page last updated and accepted by CMS January 2008.

MedicareBlue PPO and MedicareBlue Rx coverage is provided by only one of the following plans, depending on the state in which the policy is issued: Wellmark Blue Cross and Blue Shield of Iowa,* Blue Cross and Blue Shield of Minnesota,* Blue Cross and Blue Shield of Montana,* Blue Cross and Blue Shield of Nebraska,* Blue Cross Blue Shield of North Dakota,* Wellmark Blue Cross and Blue Shield of South Dakota,* and Blue Cross Blue Shield of Wyoming.*

*Independent licensees of the Blue Cross and Blue Shield Association.

R5566_122007_B07 RE

S5743_122007_B08 RE