Medicare Advantage Plan Documents
Find the documents you need to manage your Medicare Advantage Prescription Drug plan offered by Blue Cross and Blue Shield of Illinois.
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Blue Cross Medicare Advantage Basic (HMO)SM
2019 Annual Notice of Change Basic (HMO) English | español
2019 Evidence of Coverage Basic (HMO) English | español
2019 Summary of Benefits English | español
2019 Enrollment Form (HMO/HMO-POS) English | español
2019 Plan Star Rating (HMO) English | español
2019 Drug Formulary Basic (HMO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Provider Directory (HMO/HMO-POS) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Evidence of Coverage and Directory Online Request Form English | español
2019 Low Income Premium Subsidy (MAPD) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Select (HMO)SM
2019 Evidence of Coverage Select (HMO) English | español
2019 Summary of Benefits Select (HMO) English | español
2019 Plan Star Rating (HMO) English | español
2019 Drug Formulary Select (HMO) English | español
2019 Pharmacy Directory Select (HMO) English | español
2019 Provider Directory Select (HMO-POS) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Evidence of Coverage and Directory Online Request Form English | español
2019 Low Income Premium Subsidy (MAPD) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Basic Plus (HMO-POS)SM
2019 Annual Notice of Change Basic Plus (HMO-POS) English | español
2019 Evidence of Coverage Basic Plus (HMO-POS) English | español
2019 Summary of Benefits English | español
2019 Enrollment Form (HMO/HMO-POS) English | español
2019 Plan Star Rating (HMO/HMO-POS) English | español
2019 Drug Formulary (HMO-POS) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Provider Directory (HMO/HMO-POS) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Evidence of Coverage and Directory Online Request Form English | español
2019 Low Income Premium Subsidy (MAPD) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Premier Plus (HMO-POS)SM
2019 Annual Notice of Change Premier Plus (HMO-POS) English | español
2019 Evidence of Coverage Premier Plus (HMO-POS) English | español
2019 Summary of Benefits English | español
2019 Enrollment Form (HMO/HMO-POS) English | español
2019 Plan Star Rating (HMO/HMO-POS) English | español
2019 Drug Formulary (HMO-POS) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Provider Directory (HMO/HMO-POS) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Evidence of Coverage and Directory Online Request Form English | español
2019 Low Income Premium Subsidy (MAPD) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Elite (HMO-POS)SM
2019 Annual Notice of Change Elite (HMO-POS) English | español
2019 Evidence of Coverage Elite (HMO-POS) English | español
2019 Summary of Benefits (HMO-POS) English | español
2019 Enrollment Form (HMO-POS) English | español
2019 Plan Star Rating (HMO-POS) English | español
2019 Drug Formulary Elite (HMO-POS) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Provider Directory (HMO-POS) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Evidence of Coverage and Directory Online Request Form English | español
2019 Low Income Premium Subsidy (MAPD) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)SM
2019 Annual Notice of Change Choice Plus (PPO) English | español
2019 Evidence of Coverage Choice Plus (PPO) English | español
2019 Summary of Benefits (PPO) English | español
2019 Enrollment Form (PPO) English | español
2019 Plan Star Rating (PPO) English | español
2019 Drug Formulary Choice Plus (PPO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Provider Directory (PPO) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Evidence of Coverage and Directory Online Request Form English | español
2019 Low Income Premium Subsidy (MAPD) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Premier (PPO)SM
2019 Annual Notice of Change Choice Premier (PPO) English | español
2019 Evidence of Coverage Choice Premier (PPO) English | español
2019 Summary of Benefits (PPO) English | español
2019 Enrollment Form (PPO) English | español
2019 Plan Star Rating (PPO) English | español
2019 Drug Formulary Choice Premier (PPO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Provider Directory (PPO) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Evidence of Coverage and Directory Online Request Form English | español
2019 Low Income Premium Subsidy (MAPD) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Basic (HMO)SM
2020 Annual Notice of Change Basic (HMO) English | español
2020 Evidence of Coverage Basic (HMO) English | español
2020 Summary of Benefits English | español
2020 Enrollment Form (HMO/HMO-POS) English | español
2020 Drug Formulary Basic (HMO) English | español
2020 Find a Doctor or Hospital English | español
2020 Find a Pharmacy English | español
2020 Plan Star Rating (HMO) English | español
2020 Low Income Premium Subsidy (MAPD) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Basic Plus (HMO-POS)SM
2020 Annual Notice of Change Basic Plus (HMO-POS) English | español
2020 Evidence of Coverage Basic Plus (HMO-POS) English | español
2020 Summary of Benefits English | español
2020 Enrollment Form (HMO/HMO-POS) English | español
2020 Plan Star Rating (HMO/HMO-POS) English | español
2020 Drug Formulary Basic Plus (HMO-POS) English | español
2020 Find a Doctor or Hospital English | español
2020 Find a Pharmacy English | español
2020 Low Income Premium Subsidy (MAPD) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Premier Plus (HMO-POS)SM
2020 Annual Notice of Change Premier Plus (HMO-POS) English | español
2020 Evidence of Coverage Premier Plus (HMO-POS) English | español
2020 Summary of Benefits English | español
2020 Enrollment Form (HMO/HMO-POS) English | español
2020 Drug Formulary Premier Plus (HMO-POS) English | español
2020 Plan Star Rating (HMO/HMO-POS) English | español
2020 Find a Doctor or Hospital English | español
2020 Find a Pharmacy English | español
2020 Low Income Premium Subsidy (MAPD) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)SM
2020 Annual Notice of Change Choice Plus (PPO) English | español
2020 Evidence of Coverage Choice Plus (PPO) English | español
2020 Summary of Benefits (PPO) English | español
2020 Enrollment Form (PPO) English | español
2020 Plan Star Rating (PPO) English | español
2020 Drug Formulary Choice Plus (PPO) English | español
2020 Find a Doctor or Hospital English | español
2020 Find a Pharmacy English | español
2020 Low Income Premium Subsidy (MAPD) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Premier (PPO)SM
2020 Annual Notice of Change Choice Premier (PPO) English | español
2020 Evidence of Coverage Choice Premier (PPO) English | español
2020 Summary of Benefits (PPO) English | español
2020 Enrollment Form (PPO) English | español
2020 Plan Star Rating (PPO) English | español
2020 Drug Formulary Choice Premier (PPO) English | español
2020 Find a Doctor or Hospital English | español
2020 Find a Pharmacy English | español
2020 Low Income Premium Subsidy (MAPD) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
Last Updated: 09302019
Y0096_WEB_IL_MM20
Last Updated: 09302019
Y0096_WEB_IL_MM20