Get Bluecare Plus Image

This guide provides a clear and supportive overview of how to fill out the Bluecare Plus Image form online. By following these steps, users can effectively request a redetermination for a denied Medicare prescription drug coverage.

Follow the steps to complete the Bluecare Plus Image form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the enrollee's information in the designated fields. This includes the enrollee's name, date of birth, address, phone number, and plan ID number.
3. If the request is being made by someone other than the enrollee, complete the requestor's information, including their name, relationship to the enrollee, address, and phone number.
4. Attach any necessary documentation showing authority to represent the enrollee, if applicable. This may include the Authorization of Representation Form CMS-1696 or a written equivalent.
5. Specify the prescription drug being requested by entering the name of the drug, its strength, quantity, and dosage.
6. Indicate whether the drug has been purchased pending the appeal. If 'Yes,' provide the date purchased, amount paid, and the name and contact number of the pharmacy.
7. Fill in the prescriber's information, including their name, address, phone number, and fax number.
8. If requesting an expedited decision, check the appropriate box, and attach any supporting statements from the prescriber.
9. Provide a detailed explanation of the reasons for the appeal, and attach any additional supporting documents, if necessary.
10. Sign and date the form, ensuring that the request is completed by the enrollee, prescriber, or designated representative.
11. Once all fields are filled out, users can save the changes, download, print, or share the completed form as needed.

Take the next step in your appeal by completing the Bluecare Plus Image form online today.