Plans and coverage
- Summary of Benefits
Provides a summary of payment and coverage information
- Pre-enrollment checklist
Tips to help you understand the plan’s benefits and rules
- Formulary: Comprehensive list of all drugs covered by the plan
- Pharmacy directory: Plan members find pharmacy information here. Order a free print copy sent by mail.
- Paper enrollment form
Complete this form by entering your information on your computer and then printing the document. You can also print the form and fill it out by hand.
- Paper change form
To change to a different Journey Rx plan, complete this form by entering your information on your computer and then printing the document. You can also print the form and fill it out by hand.
2019 Basic Blue Rx Annual Notice of Changes (ANOC) for members who are Michigan residents in 2018
Details specific changes made to the plan at the start of each plan year.
- Evidence of Coverage: Contains a full breakdown of payment and coverage information
- Member Guide: Coverage information for your 2019 prescription drug plan
- Mail-order prescription form
Use this form if you would like your drugs to be mailed to you
- Electronic funds transfer (EFT)
Use this form to set up automatic payments of your monthly bill
- Prescription drug claim form - Part D (updated 4/1/19)
Use this form to submit a claim for purchased drugs covered by Medicare Part D. Find frequently asked questions on how to use the form
- Coverage determinations (Prior authorization or exceptions)
Use these forms to request a coverage decision (sometimes called a prior authorization or exception) for a drug in your treatment plan when your health care provider or pharmacist tells you that we will not cover the prescription. Read additional information or use the online form or printable form if this is your first coverage request for a drug.
Use the online form or printable form if you are appealing a previously denied request.
- Quantity limit exception form
- Step therapy exception form
- Tiering exception form
- Hospice exception form
- No longer in hospice exception form
- Formulary exception form
- Prior authorization criteria
- Plan transition policy
This policy details how to get coverage when transitioning to a Journey Rx plan. Contact Customer Service with any questions
- Medication Therapy Management Program
The goal of this program is to help you get the best results from your medication at the lowest possible price. Contact Customer Service with any questions. Download your Personal medication list form.
- Covered over-the-counter insulin and insulin administration
Certain Insulin medications and over-the-counter supplies require a prescription to be covered
- High risk medications - safer drug choices
View a list of high-risk drug alternatives for those eligible for Medicare coverage
- Appointing a representative - You may choose someone to act on your behalf in filing a grievance and requesting a coverage determination or redetermination
- Authorization to release information - Use this form to provide Protected Health Information (PHI) to a person or organization on your behalf
- Confidential communication request - Complete this form if you want Journey Rx to use a different address when sending member communications including claim-related material to you. There may be others involved in your health care that you may want to contact to make a similar request.
- Notice of privacy practices
Planes y cobertura
- Formulario de inscripcion: Journey Rx
- Evidencia de cobertura - Standard (EOC) (updated 7/1/19)
- Evidencia de cobertura - Value (EOC) (updated 7/1/19)
- Directorio de farmacias - Value (California) (updated 8/1/19)
- Directorio de farmacias -Standard (California) (updated 8/1/19)
- Resumen de beneficios
- Lista de verificación de preinscripción de Journey RxTM (PDP)
- Formulario - Value (updated 8/1/19)
- Formulario - Standard (updated 8/1/19)
- Pago con transferencia electrónica de fondos (EFT)
- Información de cobertura de su plan de medicamentos recetados 2019
Información representativa y confidencial
Recetas y pagos
- Formulario de pedido por correo de medicamento recetado
- Parte D de Medicare Formulario de Reclamación (updated 4/1/19)
- Formulario para Ordenar El Servicio por Correo