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 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.*
2010 Enrollment
Only those turning 65 or who are eligible for a special election period can still enroll in RxBLUE (PDP) or a 2010 start date. Certain enrollment restrictions apply.
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.
FOR PART D-COVERED VACCINATIONS: Please view special instructions for filling out the claim form.
Request for Medicare Prescription Drug Coverage Determination
You or an appointed representative can complete this form to request a coverage determination.
CMS Request for Medicare Prescription Drug Determination Form
To request a coverage determination, you may use the RxBLUE (PDP) form above or this CMS 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 this form.
CMS Appointment of Representation Form
To appoint a representative, you may use the RxBLUE (PDP) form above or this 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 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.
Our Organization contracts with the Federal government. RxBLUE (PDP) is a stand-alone prescription drug plan with a Medicare contract.
*Note: Files in Adobe PDF format require Adobe Acrobat Reader to open. You can download Adobe Acrobat Reader for free by clicking the graphic below.
Pending CMS Approval
