Anthem Blue Cross MedicareRx Standard (PDP) Documents

These documents provide a closer look at our Part D prescription drug plan. The plan documents listed below may be available in other languages. Or, if you have special needs, the documents may be available in other formats. Please call Customer Service for details.

Plan Overview:

• Anthem Blue Cross MedicareRx Standard (PDP) Summary of Benefits  The Summary of Benefits document contains a benefit comparison chart showing premiums, cost shares, and additional benefit information. Also includes the Star Ratings and Multi-language Interpreter Services documents.

Plan Details:

• Anthem Blue Cross MedicareRx Standard (PDP) Star Rating
• Multi-language Interpreter Services
• Anthem Blue Cross MedicareRx Standard (PDP) Evidence of Coverage
• Anthem Blue Cross MedicareRx Standard (PDP) Annual Notice of Changes
• Anthem Blue Cross MedicareRx Standard (PDP) 2016 Comprehensive Formulary
• Grievances, Appeals and Exceptions Information

Enrollment:

• Enrollment Instructions
• Anthem Blue Cross MedicareRx (PDP) Enrollment Form
• Medicare beneficiaries may also enroll in Anthem Blue Cross MedicareRx Standard (PDP) through the CMS Medicare Online Enrollment Center, located at www.medicare.gov.

Using the Plan:

• Service Area
• Prescription Drug Claim Form
• Prescription Drug Home Delivery Order Form
• Low Income Subsidy (LIS) Premium Summary Table For more information about receiving extra help to pay for your prescription drug coverage: In certain cases, CMS systems do not reflect a beneficiary’s correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan. In order to address these special situations, CMS has created the Best Available Evidence (BAE) policy. This policy requires Part D plans to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information is not accurate. For more information, review the CMS policy.
• Appointment of Representative Form  An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal. Those not authorized under state law to act for you will need to sign an Appointment of Representative Form and mail or fax it to Customer Service.
• Prior Authorization Criteria (includes the Part B vs. Part D coverage determination information)
• Quantity Limits (Refer to the Comprehensive Formulary for more information)
• Prescription Drug Transition Policy
• Step Therapy Criteria
• Request for Medicare Prescription Drug Coverage Determination Form Need to request an exception to the formulary? This form contains the coverage determination (including exceptions) request form.You or your physician can send a request for a prescription coverage determination or an appeal for a Medicare plan via email by sending the request to the following address: [email protected] Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
• Request for Redetermination (Appeal) of Medicare Prescription Drug Denial This form provides basic information to enrollees and prescribers on how to ask for a redetermination from a Medicare drug plan.
• Part D Conditions and Limitations By law, certain types of drugs or categories of drugs are not covered by Medicare Prescription Drug Plans. These drugs or categories of drugs are called “exclusions”.
• Out of Network Prescription Drug Coverage Review the procedures for filling prescriptions outside of the network.
• Quality Assurance (for plans with prescription drug benefits)
• Medication Therapy Management Program (MTMP) Information Please note that this program is not considered a benefit.
• Participating Medicare Part D Pharmacy Locator
• Anthem Blue Cross MedicareRx Prescription Drug Formulary
• Contact Us

Forms for Physicians:

• Medicare Part D Coverage Determination and Prior Authorization Request Form (for use by physicians): This form is used by physicians to provide a supporting statement for an exceptions request or to submit a prior authorization request. A physician can send a request for a prescription coverage determination or an appeal for a Medicare plan via email by sending the request to the following address: [email protected] Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.

Overview of Medicare:

• Medicare and You