2027 Documents
Enrollment
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Enrollment Form (PDF)S2893_2617_C |
Last Updated 10/01/2026 -
Sales Brochure (PDF)S2893_2611_M |
Last Updated 10/01/2026 -
Pre-Enrollment Checklist (PDF)S2893_2613_C |
Last Updated 10/01/2026
Plan Documents
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Blue MedicareRx Value Plus Evidence of Coverage (PDF)S2893_2604_C |
Last Updated 10/01/2026 -
Blue MedicareRx Value Plus Annual Notification of Change (PDF)S2893_2603_M |
Last Updated 10/01/2026 -
Blue MedicareRx Premier Evidence of Coverage (PDF)S2893_2604_C |
Last Updated 10/01/2026 -
Blue MedicareRx Premier Annual Notification of Change (PDF)S2893_2603_M |
Last Updated 10/01/2026 -
Summary of Benefits (PDF)S2893_2612_M |
Last Updated 10/01/2026 -
Plan Rating Sheet (PDF)S2893_2592_M |
Last Updated 10/01/2026
News & Tips
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Medicare Prescription Payment Plan Fact Sheet (PDF)Last Updated 10/01/2025
Formulary / Drug Coverage
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Blue MedicareRx Value Plus Comprehensive Formulary (PDF)S2893_2605_C |
Last Updated 10/01/2026 -
Blue MedicareRx Premier Comprehensive Formulary (PDF)S2893_2605_C |
Last Updated 10/01/2026 -
Blue MedicareRx Prior Authorization Criteria Value Plus (PDF)Last Updated 10/01/2026
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Blue MedicareRx Prior Authorization Criteria Premier (PDF)Last Updated 10/01/2026
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Blue MedicareRx Step Therapy Criteria Value Plus (PDF)Last Updated 10/01/2026
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Blue MedicareRx Step Therapy Criteria Premier (PDF)Last Updated 10/01/2026
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Drug Coverage Determination Request Form (PDF)Last Updated 10/01/2026
Pharmacies / Claims
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Mail Service Order Form / Instructions (PDF)Last Updated 10/01/2026
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Prescription Claim Form (PDF)Last Updated 10/01/2026
Related Documentation
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Appointment of Representative Form (PDF)Last Updated 10/01/2026
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LIS Premium Summary (PDF)S2893_2636_C |
Last Updated 10/01/2026 -
Non-Discrimination Notice (PDF)S2893_1709 |
Last Updated 10/01/2026 -
Notice of Availability (PDF)S2893_2511 |
Last Updated 10/01/2026