2021 Employer group plan and coverage documents

• Pre-enrollment checklist
  Tips to help you understand the plan's benefits and rules.

• MedicareBlue Rx Star Rating
  View our Star Rating from Medicare. The Star Rating is updated by Medicare each year.

• Evidence of Coverage (EOC)
  Provides details about your prescription drug plan benefits, how to get coverage for prescriptions and important contact information.
  • 4-tier Evidence of Coverage
  • 5-tier Evidence of Coverage

• Formulary (drug list)
  A list of all the drugs that are covered by the plan.
  • 4-tier Formulary (09/01/2021)
  • 5-tier Formulary (09/01/2021)
  • Supplemental drug list
  • Supplemental plus drug list

• Pharmacy directory
  Use the plan pharmacy locator tool to find a pharmacy near you, or have a printed copy mailed to you.

Mail order, automatic payment and claims documents

• Mail order prescription form
  Complete this form if you would like to receive your prescriptions through our mail order pharmacy service. You can also sign up at Caremark.com.

• Electronic funds transfer (EFT) form
  Set up automatic payments for your monthly premium by completing this EFT form. You can also sign up for EFT online.

• Drug claim forms
  Use the applicable form to submit a claim. If you need to be reimbursed for a compound drug or vaccine, please submit the Medicare Part D prescription claims form along with the corresponding compound or vaccine claim form below for faster processing. Learn how to use the claim form.
  • Part D prescription drug claim form
    
  • Compound prescription drug claim form
  • Vaccine claim form

  Coverage decision, redetermination and exception documents

  • Coverage determinations
    Use the forms below to request a coverage decision (sometimes called a prior authorization or an exception) if you take a drug that isn't covered by our plan. Read more about coverage decisions.
    • Online coverage decisions form
    • Printable coverage decision form
  • Coverage redetermination
    If you are appealing a previously denied coverage decision, use the forms below.
    • Online redetermination form
    • Printable redetermination form
  • Drug exception forms
    If you would like to request a coverage exception, use the applicable form below.
    • Quantity limit exception form
    • Step therapy exception form
    • Tiering exception form
    • Hospice exception form
    • Update hospice status form
    • Formulary (drug list) exception form
  • Step therapy criteria information
    Some drugs on our drug list have step therapy requirements that must be met before we will cover the drug.
    • 4-tier step therapy criteria
    • 5-tier step therapy criteria
  • Prior authorization criteria information
    Some drugs on our drug list have prior authorization requirements that must be met before we will cover the drug.
    • 4-tier prior authorization criteria (09/01/2021)
    • 5-tier prior authorization criteria (09/01/2021)

  Drug policies and programs

  • Plan transition drug supply policy
    This policy details how to get coverage when transitioning to a Group MedicareBlue Rx plan. Contact customer service with questions.
  • Medication therapy management (MTM) program
    MTM is a program to help you get the best results from your medication at the lowest cost. Members who meet certain requirements are eligible for this program. If you qualify, we will contact you directly.
    • Personal medication list sample
  • Over-the-counter drug and supply coverage
    Some insulin medication and over-the-counter supplies require that you have a prescription before the plan can cover them.
  • High-risk medication alternatives
    See alternatives for some commonly prescribed high-risk medications. Talk with your doctor or pharmacist if you re interested in learning more about alternatives for high-risk medications.

  Appointing a representative and confidential information documents

  • Appoint a representative
    You can choose someone to file grievances, request coverage decisions and redeterminations on your behalf.
  • Authorization to release information
    You can give us permission to give your protected health information (PHI) to a person or organization on your behalf.
  • Confidential communication request form
    You can request to have member communications, including claims-related information, mailed to a different address than your permanent address.
  • Our privacy practices
    Learn how information about you may be used and disclosed and how you can get access to this information.

  Medicare resources

  • Medicare & You: The official U.S. government Medicare handbook (updated 10/07/20)
    In this handbook you will get a thorough explanation about the Medicare program, when you can enroll, your rights as a beneficiary and much more. Medicare updates the handbook each year.
  • How Medicare Works: An information guide to help you make the most of your Medicare coverage (updated 12/15/20)
    Explore this guide to learn about Medicare and determine the best level of coverage for your needs.