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.
2020 Plan Documents
2020 Annual Notice of Changes English | Spanish
2020 Member Handbook (includes document of coverage information) English | Spanish
2020 Drug List (Formulary) English | Spanish
Key Plan Forms and Documents
Critical Incident Form for Members English | Spanish
Drug Mail Order Form English | Spanish
HIPAA Privacy Notice of Privacy Practices English | Spanish
Medicare & Medicaid Forms
Request for Medicare Prescription Drug Coverage Determination
Request for Redetermination of Medicare Prescription Drug Denial
Utilization Management Forms
Prior Authorization Criteria and Form
Quantity Limits Exception Form
Step Therapy Criteria and Form
View these forms and documents in Spanish. If you have questions, please Contact Us.
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
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
Medicare & Medicaid Forms
Request for Medicare Prescription Drug Coverage Determination
Request for Redetermination of Medicare Prescription Drug Denial
Utilization Management Forms
Prior Authorization Criteria and Form
Quantity Limits Exception Form
Step Therapy Criteria and Form
View these forms and documents in Spanish. If you have questions, please Contact Us.