Medicare Advantage Plan Documents
Find the documents you need to manage your Medicare Advantage or Medicare Advantage Prescription Drug plan offered by Blue Cross and Blue Shield of Illinois.
View these forms and documents in Spanish. If you have questions, please Contact Us.
Find the documents you need to manage your Medicare Advantage or Medicare Advantage Prescription Drug plan offered by Blue Cross and Blue Shield of Illinois.
View these forms and documents in English. If you have questions, please Contact Us.
Champaign, Springfield, and Decatur Areas
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver Plus (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
Chicago Area
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- H3822001
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H3822014
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
Prescription Drug Information
- Drug Formulary Basic (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H3822001
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Summary of Benefits – Last Updated 09/30/2022
- H3822014
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
Prescription Drug Information
- Drug Formulary Basic (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H3822001
-
Blue Cross Medicare Advantage Basic Plus (HMO-POS)SM
General Plan Information- Annual Notice of Change Basic (HMO-POS) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO-POS) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO-POS) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO-POS) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO-POS) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO-POS) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (HMO-POS) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO-POS)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change Basic (HMO-POS) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO-POS) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO-POS) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO-POS) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO-POS) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (HMO-POS) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO-POS)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Choice Premier (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- H8634008
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H8634012
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
Prescription Drug Information
- H8634008
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Pharmacy Directory – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- H8634012
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Pharmacy Directory – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H8634008
- Annual Notice of Change Basic (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H8634012
- Annual Notice of Change Basic (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
Prescription Drug Information
- H8634008
- Drug Formulary Basic (PPO) – Last Updated 03/01/2023
- Pharmacy Directory – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- H8634012
- Drug Formulary Basic (PPO) – Last Updated 03/01/2023
- Pharmacy Directory – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H8634008
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Elite (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change Basic (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Premier Plus (HMO-POS)SM
General Plan Information- Annual Notice of Change Basic (HMO-POS) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO-POS) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO-POS) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO-POS) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO-POS) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO-POS) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (HMO-POS) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO-POS)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change Basic (HMO-POS) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO-POS) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO-POS) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO-POS) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (HMO-POS) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO-POS)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver Plus (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Medicare Advocate Health (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
Evansville Area
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change Basic (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change Basic (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
Paducah, Cape Girardeau, and Harrisburg Areas
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- H3822012
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H3822013
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H3822014
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
Prescription Drug Information
- Drug Formulary Basic (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H3822012
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Summary of Benefits – Last Updated 09/30/2022
- H3822013
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Summary of Benefits – Last Updated 09/30/2022
- H3822014
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
Prescription Drug Information
- Drug Formulary Basic (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H3822012
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- H8634011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
- H8634013
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
- H8634017
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H8634011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
- H8634013
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
- H8634017
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H8634011
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 01/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 01/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 01/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 01/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change Basic (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change Basic (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
Peoria and Bloomington Areas
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- H3822012
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H3822014
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H3822015
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
Prescription Drug Information
- Drug Formulary Basic (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H3822012
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Summary of Benefits – Last Updated 09/30/2022
- H3822014
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Summary of Benefits – Last Updated 09/30/2022
- H3822015
- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
Prescription Drug Information
- Drug Formulary Basic (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H3822012
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- H8634012
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H8634013
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H8634012
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H8634013
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H8634012
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver Plus (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
Quincy, Hannibal, and Keokuk Areas
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- H3822012
- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H3822014
- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H3822012
- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Summary of Benefits – Last Updated 09/30/2022
- H3822014
- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H3822012
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver Plus (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
Rockford, Davenport, Rock Island, and Moline Areas
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver Plus (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
St. Louis Area
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- H3822012
- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H3822013
- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H3822012
- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Summary of Benefits – Last Updated 09/30/2022
- H3822013
- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H3822012
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- H8634011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
- H8634017
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H8634011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
- H8634017
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H8634011
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver Plus (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
Terre Haute Area
-
Blue Cross Medicare Advantage Basic (HMO)
General Plan Information- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change Basic (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) – Last Updated 09/30/2022
- Evidence of Coverage Basic (HMO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary Basic (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/15/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
Last Updated: July 18, 2023
Last Updated: 09302022
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