Coverage Determination form

Please complete one form per Medicare Prescription Drug you are requesting a Coverage Determination for.

This form may also be sent to us by mail or fax:

Fax Number: 1-855-633-7673

You may also ask us for a coverage determination by phone 24 hours a day, 7 days a week by calling the telephone number on the back of your Blue MedicareRx id card.

All fields are optional unless marked required.

Blue MedicareRx (PDP) is a Prescription Drug Plan with a Medicare contract. Blue MedicareRx Value Plus (PDP) and Blue MedicareRx Premier (PDP) are two Medicare Prescription Drug Plans available to service residents of Connecticut, Massachusetts, Rhode Island, and Vermont.

Coverage is available to residents of the service area or members of an employer or union group and separately issued by one of the following plans: Anthem Blue Cross ® and Blue Shield ® of Connecticut, Blue Cross Blue Shield of Massachusetts, Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont.

S2893_2309 Page Last Updated 10/01/2023.

CVS Caremark is an independent company that has been contracted to administer pharmacy benefits and provide certain pharmacy services for Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont who are the legal entities which have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx (PDP) plans.

Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are Independent Licensees of the Blue Cross and Blue Shield Association®, SM, TM Registered and Service Marks and Trademarks are property of their respective owners. ® , SM, TM Registered and Service Marks and Trademarks are property of their respective owners.
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