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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.

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Medicare with Medicaid (BlueCare PlusSM)

Annual Notice of Changes

The Annual Notice of Change describes the changes to your plan's costs and benefits from the previous year.

Benefits & Coverage

These documents contain information about your benefits, network and coverage.

Enrollment

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.

Evidence of Coverage

Download a complete list of your plan's coverage, cost and benefits, also called your Evidence of Coverage.

Grievances & Appeals

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.

Pharmacies & Prescriptions

These documents offer information about your covered drug benefits.

Summary of Benefits

Download a simplified list of your plan's benefits and coverage, also called the Summary of Benefits.

Wellness

Use these resources to help you get the care you need and stay well.

Your Rights

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.