Employer group documents for 2019

Employer group documents for 2020

Plan & coverage  go back

Prescriptions & payments  go back

Drug claims & alternatives  go back

  • Coverage determinations (Prior authorization or exceptions)
    Use these forms to request a coverage decision (sometimes called a prior authorization or exception) for a drug in your treatment plan when your health care provider or pharmacist tells you that we will not cover the prescription. Read additional information or use the online form or printable form if this is your first coverage request for a drug.
  • Redetermination
    Use the online form or printable form if you are appealing a previously denied request.

Medication policies and programs  go back

Representative & confidential information go back

  • Appointing a representative - You may choose someone to act on your behalf in filing a grievance and requesting a coverage determination or redetermination.
  • Authorization to release information - Use this form to provide Protected Health Information (PHI) to a person or organization on your behalf.
  • Confidential communication request - Complete this form if you want Group MedicareBlue Rx to use a different address when sending member communications including claim related material to you. There may be others involved in your healthcare you may want to contact to make a similar request.
  • Notice of privacy practices