Documents & Forms
We've put together the most common documents and forms you might need for things like filing claims or reviewing your coverage. Start by choosing what kind of insurance you have from the list below.
- Through Your Employer
- Individual & Family
- Medicare Advantage (BlueAdvantage)
- Medicare Advantage (BlueEssential)
- Medicare Supplement
- Medicaid with Medicare (BlueCare Plus℠)
These documents contain information about your benefits, network and coverage.
Use these forms to file an appeal about coverage or payment decisions, or to file grievance if you have concerns about your plan, providers or quality of care.
These documents offer information about your covered drug benefits.
- 2020 Medicare with Medicaid Medication List (Formulary)
- Prescription Claim Form
- Request for Prescription Coverage Determination Form
- Request for Prescription Redetermination Form
- Prescription Home Delivery Form
- Part D Out of Network Coverage
- Prior Authorization Criteria
- Step Therapy Criteria
- Quality Assurance Policies and Procedures
- Transition Policies and Procedures
- Over-the-Counter Order Form
- One Touch® Free Blood Glucose Monitor Voucher
- Ascensia® Contour Free Blood Glucose Monitor Voucher
- January 2020 Prescription Drug List
You'll find notices and forms in this section that will help you understand your rights and responsibilities, and make requests related to those rights.
Use these resources to help you enroll in a plan. If you have a BlueCare Plus plan, you can ignore the “subsidy tables.” You won’t pay a monthly premium payment while you have this plan.
Use these resources to help you get the care you need and stay well.
The Annual Notice of Change describes the changes to your plan's costs and benefits from the previous year.