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
- Annual Notice of Changes – Last Updated 09/30/2022
- Member Handbook (includes document of coverage information) – Last Updated 12/13/2022
- Drug List (Formulary) – Last Updated 09/30/2022
- Provider and Pharmacy Directory – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Annual Notice of Changes – Last Updated 09/30/2022
- Member Handbook (includes document of coverage information) – Last Updated 12/13/2022
- Drug List (Formulary) – Last Updated 09/30/2022
- Provider and Pharmacy Directory – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Privacy Documents
- Critical Incident Form for Members – Last Updated 09/30/2022
- AllianceRx Walgreens Pharmacy Mail-Order Form
- Express Scripts® Pharmacy Mail-Order Form
- Frequently Asked Questions – Last Updated 09/30/2022
- HIPAA Notice of Privacy Practices – Last Updated 09/30/2022
- Prescription Drug Transition Policy – Last Updated 09/30/2022
- Power of Attorney
- Appointment of Representative – Last Updated 09/30/2022
- Quality Improvement Form – Last Updated 09/30/2022
- Critical Incident Form for Members – Last Updated 09/30/2022
- AllianceRx Walgreens Pharmacy Mail-Order Form
- Express Scripts® Pharmacy Mail-Order Form
- Frequently Asked Questions – Last Updated 09/30/2022
- HIPAA Notice of Privacy Practices – Last Updated 09/30/2022
- Prescription Drug Transition Policy – Last Updated 09/30/2022
- Power of Attorney
- Appointment of Representative – Last Updated 09/30/2022
- Quality Improvement Form – Last Updated 09/30/2022
Medicare & Medicaid Forms
- Request for Medicare Prescription Drug Coverage Determination – Last Updated 09/30/2022
- Request for Redetermination of Medicare Prescription Drug Denial – Last Updated 09/30/2022
- Request for Payment for Medicare Part D Drugs – Last Updated 09/30/2022
- Request for Medicare Prescription Drug Coverage Determination – Last Updated 09/30/2022
- Request for Redetermination of Medicare Prescription Drug Denial – Last Updated 09/30/2022
- Request for Payment for Medicare Part D Drugs – Last Updated 09/30/2022