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Forms and Alternate Formats
Use the forms below to manage your Blue MedicareRxSM coverage.
Appointment of Representative 
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 for additional information.
Este material está disponible en otros formatos, incluida la traducción al Español. Contacte nuestro numero de Servicio al Cliente para obtener información adicional.
| Materials in English | Materiales en Español |
|---|---|
Summary of Benefits  S5715_TX_BEN_BNFTSMRY13 |
Summary of Benefits en Español S5715_TX_BEN_BNFTSMRY13SPA Accepted 09162012 |
|
Drug List S5715_MRK_TX_ TMP_FRMLRY13a Accepted 09282012 |
Drug list en Español S5715_MRK_TX_ TMP_FRMLRY13aSPA |
|
Pharmacy Directory S5715_BEN_TMP_RXDRCTRY13 Accepted 10012012 |
Pharmacy Directory en Español S5715_BEN_TMP_RXDRCTRY13SPA Accepted 10012012 |
|
Evidence of Coverage: Value Plan S5715_BEN_TX_EOCVALUE2013 |
Evidence of Coverage: Value Plan en Español S5715_BEN_TX_ANOCEOCVALUE2013SPA |
|
Evidence of Coverage Plus Plan S5715_BEN_TX_ANOCEOCPLS2013 |
Evidence of Coverage: Plus Plan en Español S5715_BEN_TX_ANOCEOCPLS2013SPA |
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company,
an Independent Licensee of the Blue Cross and Blue Shield Association.
© Copyright 2013. 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 Texas 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 10262012
[H1666/S5715]_WEB_TX_PDP13a Pending
