Forms and Alternate Formats
Use the forms below to manage your Blue MedicareRxSM coverage.
Appointment of Representative 
en Español
Authorization to Disclose Protected Health Information
Automated Premium Payment (ACH) Form
Prescription Drug Mail-Order Form 
Prescription Drug Claim Form
Prior Authorization
Request for Medicare Prescription Drug Coverage Determination Form
Request for Redetermination of Medicare Prescription Drug Denial Form
Physician Fax Form
File a Grievance
Appeal Instructions
Step Therapy Form
en Español
Alternate formats for these materials, including Spanish translations, may be available. Please contact our Product Specialists at the number listed below for additional information.
Este material está disponible en otros formatos, incluida la traducción al Español. Para obtener información adicional, llame por favor a nuestros especialistas en productos al número detallado anteriormente.
| Materials in English | Materiales en Español |
|---|---|
Summary of Benefits  S5715_IL_BEN_BNFTSMRY12 CMS Approved 09122011 |
Summary of Benefits en Español S5715_IL_BEN_BNFTSMRY12SPA CMS Approved 09122011 |
|
Drug List S5715_MRK_TMP_FRMLRY12a File and Use 10012011 |
Drug List en Español S5715_MRK_TMP_FRMLRY12aSPA File and Use 10012011 |
|
Pharmacy Directory S5715_BEN_TMP_RXDRCTRY12 File and Use 10012011 |
Pharmacy Directory en Español S5715_BEN_TMP_RXDRCTRY12SPA File and Use 10012011 |
|
Evidence of Coverage: Value Plan S5715_BEN_IL_ANOCEOCVALUE2012 File and Use 09022011 |
Evidence of Coverage: Value Plan en Español S5715_BEN_IL_ANOCEOCVALUE2012SPA File and Use 09022011 |
|
Evidence of Coverage Plus Plan S5715_BEN_IL_ANOCEOCPLS2012 File and Use 08302011 |
Evidence of Coverage: Plus Plan en Español S5715_BEN_IL_ANOCEOCPLS2012SPA File and Use 08302011 |
Need Assistance?
Blue MedicareRx
Call 1-877-213-1821
This information is available for free in other languages. Please contact our Customer Service number at 1-877-213-1821 for additional information. (TTY/TDD users should call 711). Hours are 8 a.m. - 8 p.m., local time, 7 days a week. From February 15th through October 14th alternate technologies (for example, voicemail) will be used on the weekends and holidays. Customer Service also has free language interpreter services available for non-English speakers. en Español
Contact us:
Blue MedicareRx
P.O. Box 3897
Scranton, PA 18505-9947
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association.
© Copyright 2012. Health Care Service Corporation. All Rights Reserved.
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Important Information about Blue MedicareRx
SM Service Mark of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.
® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.
Blue Cross and Blue Shield of Illinois refers to HCSC Insurance Services Company, which is a wholly owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for stand-alone prescription drug plans with a Medicare contract under contract number S5715 with the Centers for Medicare and Medicaid Services.
A stand-alone prescription drug plan with a Medicare contract.
Last Updated 01202012S5715_WEB_IL_PDP12d
CMS Approved 02092012
