Forms and Document

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.

2021 Plan Documents

2021 Annual Notice of Changes English | Spanish

2021 Member Handbook (includes document of coverage information) English | Spanish

2021 Drug List (Formulary) English | Spanish

2021 Provider and Pharmacy Directory English | Spanish

2021 Summary of Benefits English | Spanish

Privacy Documents

Critical Incident Form for Members  English | Spanish

Drug Mail Order Form  English | Spanish

Frequently Asked Questions English | Spanish

HIPAA Privacy 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