RxBLUE PDP Forms for 2012

Below are forms you will need in order to enroll in and manage your prescription drug plan. More information on policies and forms regarding coverage determinations, appeals and appointment of representatives can be found in the RxBLUE Basic PDP Evidence of Coverage (EOC), RxBLUE Plus PDP Evidence of Coverage (EOC) or on the Your Rights page.

All forms are in PDF format. If you cannot open these files you will need to download Adobe Acrobat Reader.*

2012 Enrollment

Open enrollment for 2012 Medicare Part D is now closed.

For Members

Claim Form
RxBLUE PDP offers automatic claims filing on your behalf. However, if you need to file a claim yourself, please use this claim form.

Request for Medicare Prescription Drug Coverage Determination
You or an appointed representative can complete the RxBLUE PDP form above to request a coverage determination or the CMS Request for Medicare Prescription Drug Determination Request form, which is located on the CMS website.

Request for Medicare Prescription Drug Redetermination
If you received an unfavorable coverage determination, you can request a redetermination of the request by submitting this form.

Appointment of Representative Form
If you want to give someone legal permission to act as your appointed representative in the appeals process, then you and that person must sign and date the CMS Appointment of Representation form, which is located on the CMS website.

Authorized Delegate Form
Complete this form if you wish to authorize another individual, organization or class of individuals/organizations to receive and access your protected health information that we create and use.

Bank Draft Authorization (Electronic Funds Transfer)
RxBLUE PDP can automatically withdraw your premium from your bank account. If you wish to set up this service, complete this authorization form and send it to Attention: Accounts Receivable, P.O. Box 98029, Baton Rouge, LA 70898-9029. Please allow 30 days to process your request.

For Physicians

Physician Coverage Determination Request
Prescribing physicians should use this form to request a coverage determination on behalf of a patient.

CMS Medicare Part D Coverage Determination Request Form
To request a coverage determination, physicians may use the RxBLUE PDP form above or this CMS request form which is located on the CMS website. 

Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company, a Medicare-approved Part D sponsor.

CMS Approved 12132011
Page Last Updated: 8:00 a.m. on 01.01.2012