Medicare Advantage Plan

FORMS	DOWNLOAD
Appointing a Representative Requesting a person to represent me or have access to my confidential information	English Español
AutoPay (ACH/EFT) Form	English
Individual Change Form	English Español
Individual Enrollment Form	Blue Best Life (HMO) - English Blue Best Life (HMO) - Español
Medicare Prescription Drug Claim Form Submit a claim for purchased drugs covered by Medicare Part D	Online Drug Claim Form English
Mail Order Prescription Form	English
Medicare Transition Policy	Medicare Transition Policy (See information below)
Prior Authorization List	English
Coverage Determination Form	Provider Online Prior Authorization Request Member Online Prior Authorization Request Coverage Determination Form - English
Step Therapy Drug List and Criteria	Part B English Part D English
Direct Member Reimbursement Form Request reimbursement for covered medical care and supplies that were paid out-of-pocket.	English
Dental Claim Form Request reimbursement for dental services that were paid out-of-pocket.	English
Continuity of Services To help make your transition into your AZ Blue Medicare Advantage plan a smooth one, this form provides information to help our Utilization Management and Care Management staff coordinate your ongoing medical services and future appointments.	English
Request for Health Records	English
Privacy Compliant Form	English

Requesting a Formulary Exception

What if your drug is not on the formulary?
If your prescription is not listed on the formulary, you should first contact AZ Blue Member Services to see if it is covered. If it is not covered, you have three options:
1. You can ask your doctor if you can switch to a drug that is already on the formulary.
2. You can ask us to make an exception and cover your drug.
3. You can pay out of pocket for the drug and request the plan reimburse you by submitting an exception request.
How can you request an exception to the formulary?
You can ask us to make an exception to our coverage rules using the Request for Medicare Prescription Coverage Determination. In order for us to make a decision, your doctor must include supporting medical information. Have your doctor fax the exception request and supporting statement to our contracted pharmacy benefit manager, OptumRx, at 1-844-883-8523, TTY: 711.

Request a Formulary Exception Online
Transitioning to and from our Medicare plan

New Members
As a continuing member in the plan, you will receive a notice on how to access your formulary online. You may notice that a formulary medication, which you are currently taking, is either not on the upcoming year’s formulary, its cost sharing has been changed, or coverage is limited.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days if you are a member of our plan. If you need a drug that is not on our formulary or your ability to get your drugs is limited, and you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Continuing Members
As a continuing member in the plan, you will receive a notice on how to access your formulary online. You may notice that a formulary medication, which you are currently taking, is either not on the upcoming year’s formulary, its cost sharing has been changed, or coverage is limited

In this case, you must work with your doctor to either find an appropriate alternative therapy on our new formulary or request a formulary exception prior to the beginning of the new year. If the exception request is approved, we will authorize payment.

AZ Blue members that move from one level of care to another as described below, AZ Blue may provide a temporary, one-time up to 30-day supply of a Part D eligible non-formulary medication. This one-time, fill needs to be authorized through the exception process. Therefore, your doctor or pharmacist will need to call our contracted pharmacy benefit administrator OptumRx at 1-844-883-8523, TTY: 711 and let them know that you are moving from one level of care to another.  

Examples of moving (or transitioning) from one level of care to another include the following:
1. Members transitioning from hospital to home (discharge medications)
2. Members transitioning from a Skilled Nursing Facility (Long Term Care Facility) and reverting to the Part D benefit
3. Members terminating a Hospice election and reverting to Part A and Part D benefit
4. Members discharged from a Chronic Psychiatric Hospital to home (discharge medications)
If you have any questions about our transition policy or need help asking for a formulary exception, call AZ Blue.

Have questions about a plan in which you are enrolled? We’re here to help.