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
2021 Annual Notice of Change Basic (HMO) English | español
2021 Evidence of Coverage Basic (HMO) English | español
2021 Summary of Benefits English | español
2021 Enrollment Form (HMO/HMO-POS) English | español
2021 Plan Star Rating (HMO) English | español
2021 Drug Formulary Basic (HMO) English | español
2021 Find a Doctor or Hospital English | español
2021 Pharmacy Directory English | español
2021 Low Income Premium Subsidy (MAPD) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Personal Medication List English | español
2021 Prescription Drug Coverage Determination Request Form (HMO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (HMO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Medicare Advocate Health (HMO)℠
2021 Evidence of Coverage (HMO) English | español
2021 Summary of Benefits English | español
2021 Enrollment Form (HMO/HMO-POS) English | español
2021 Plan Star Ratings - Plan too new to be measured
2021 Drug Formulary (HMO) English | español
2021 Find a Doctor or Hospital English | español
2021 Pharmacy Directory English | español
2021 Low Income Premium Subsidy (MAPD) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Personal Medication List English | español
2021 Prescription Drug Coverage Determination Request Form (HMO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (HMO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Basic Plus (HMO-POS)SM
2021 Annual Notice of Change Basic Plus HMO-POS) English | español
2021 Evidence of Coverage Basic Plus (HMO-POS) English | español
2021 Summary of Benefits English | español
2021 Enrollment Form (HMO/HMO-POS) English | español
2021 Plan Star Rating (HMO-POS) English | español
2021 Drug Formulary Basic Plus (HMO-POS) English | español
2021 Find a Doctor or Hospital English | español
2021 Pharmacy Directory English | español
2021 Low Income Premium Subsidy (MAPD) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Personal Medication List English | español
2021 Prescription Drug Coverage Determination Request Form (HMO-POS) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (HMO-POS) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Premier Plus (HMO-POS)SM
2021 Annual Notice of Change Premier Plus (HMO-POS) English | español
2021 Evidence of Coverage Premier Plus (HMO-POS) English | español
2021 Summary of Benefits English | español
2021 Enrollment Form (HMO/HMO-POS) English | español
2021 Plan Star Rating (HMO-POS) English | español
2021 Drug Formulary Premier Plus (HMO-POS) English | español
2021 Find a Doctor or Hospital English | español
2021 Pharmacy Directory English | español
2021 Low Income Premium Subsidy (MAPD) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Personal Medication List English | español
2021 Prescription Drug Coverage Determination Request Form (HMO-POS) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (HMO-POS) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)SM
2021 Annual Notice of Change Choice Plus (PPO) English | español
2021 Evidence of Coverage Choice Plus (PPO) English | español
2021 Summary of Benefits (PPO) English | español
2021 Enrollment Form (PPO) English | español
2021 Plan Star Rating (PPO) English | español
2021 Drug Formulary Choice Plus (PPO) English | español
2021 Find a Doctor or Hospital English | español
2021 Pharmacy Directory English | español
2021 Low Income Premium Subsidy (PPO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Personal Medication List English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Premier (PPO)SM
2021 Annual Notice of Change Choice Premier (PPO) English | español
2021 Evidence of Coverage Choice Premier (PPO) English | español
2021 Summary of Benefits (PPO) English | espanol
2021 Enrollment Form (PPO) English | español
2021 Plan Star Rating (PPO) English | español
2021 Drug Formulary Choice Premier (PPO) English | español
2021 Find a Doctor or Hospital English | español
2021 Pharmacy Directory English | español
2021 Low Income Premium Subsidy (PPO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Personal Medication List English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Classic (PPO)℠
2021 Evidence of Coverage Classic (PPO) English | español
2021 Summary of Benefits English | español
2021 Enrollment Form (PPO) English | español
2021 Plan Star Rating (PPO) English | español
2021 Drug Formulary Classic (PPO) English | español
2021 Find a Doctor or Hospital English | español
2021 Pharmacy Directory English | español
2021 Low Income Premium Subsidy (MAPD) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Personal Medication List English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
2021 Southern Illinois
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Blue Cross Medicare Advantage Basic (HMO)SM
2021 Evidence of Coverage Basic (HMO) English | español
2021 Summary of Benefits English | español
2021 Enrollment Form (HMO) English | español
2021 Plan Star Rating (HMO) English | español
2021 Drug Formulary Basic (HMO) English | español
2021 Find a Doctor or Hospital English | español
2021 Pharmacy Directory English | español
2021 Low Income Premium Subsidy (HMO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Personal Medication List English | español
2021 Prescription Drug Coverage Determination Request Form (HMO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (HMO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)SM
2021 Evidence of Coverage Choice Plus (PPO) English | español
2021 Summary of Benefits (PPO) English | español
2021 Enrollment Form (PPO) English | español
2021 Plan Star Rating (PPO) English | español
2021 Drug Formulary Choice Plus (PPO) English | español
2021 Find a Doctor or Hospital English | español
2021 Pharmacy Directory English | español
2021 Low Income Premium Subsidy (PPO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Personal Medication List English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
Last Updated: 12312020
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Last Updated: 03182021
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