Member Services

Group Plans

Forms and Brochures — Group Products

This Forms and Brochures — Group Products section provides you with easy access to the materials you will need to fill prescriptions in a retail pharmacy or by mail order. You will also find forms you can use if you wish to appeal a provision of your plan.

Quick Links to Prescription Drug Claim Forms

Use the list below to download the right prescription drug claim form:

Group MedicareBlue Rx (PDF)
Group MedicareBlue PPO (PDF)

May 11, 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