Forms and Documents

Find the forms and documents you need to manage your Blue Cross Community MMAI (Medicare-Medicaid Plan)SM offered by Blue Cross and Blue Shield of Illinois.

View these forms and documents in Spanish. If you have questions, please Contact Us.

2023 Plan Documents

Privacy Documents

Medicare & Medicaid Forms

Utilization Management Forms

2022 Plan Documents

2022 Annual Notice of Changes English | Spanish

2022 Member Handbook (includes document of coverage information) English | Spanish

2022 Drug List (Formulary) English | Spanish

2022 Provider and Pharmacy Directory English | Spanish

2022 Summary of Benefits English | Spanish

Privacy Documents

Critical Incident Form for Members English | Spanish

AllianceRx Walgreens Prime Mail-Order Form English | Spanish

Express Scripts® Pharmacy Mail-Order Form English | Spanish

Frequently Asked Questions English | Spanish

HIPAA Notice of Privacy Practices English | Spanish

Prescription Drug Transition Policy English | Spanish

Power of Attorney

Appointment of Representative English | Spanish

Quality Improvement Form English | Spanish

Medicare & Medicaid Forms

Utilization Management Forms