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Forms and Translated Materials
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  H3822_IL_BEN_BNFTSMRY13 Accepted 09152012 |
Summary of Benefits en Español H3822_IL_BEN_BNFTSMRY13SPA Accepted 09152012 |
|
Drug List H3822_MRK_IL_TMP_FRMLRY13 Accepted 09282012 |
Drug list en Español H3822_MRK_IL_TMP_FRMLRY13SPA |
|
Pharmacy Directory H3822_BEN_TMP_RXDRCTRY13a Accepted 10012012 |
Pharmacy Directory en Español H3822_BEN_TMP_RXDRCTRY13aSPA Accepted 10012012 |
|
Evidence of Coverage H3822_BEN_IL_MAPDEOC2013a Accepted 09052012 |
Evidence of Coverage en Español H3822_BEN_IL_MAPDEOC2013aSPA Accepted 09052012 |
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 Medicare Advantage:
Blue Medicare Advantage premiums apply to residents of Cook, DuPage, Kane and Will counties only.
Blue Cross and Blue Shield of Illinois, a division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an independent licensee of the Blue Cross and Blue Shield Association, is a Medicare Advantage organization with a Medicare contract under contract H3822 with the Centers for Medicare and Medicaid Services.
HCSC is a Medicare Advantage organization with a Medicare contract.
Last Updated 09282012
H3822_WEB_IL_MAPD13 Approved 10152012