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 (BlueElite)
- Medicare with Medicaid (BlueCare Plus℠)
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.
These documents contain information about your benefits, network and coverage.
- BlueCare Plus Plan Rating
- BlueCare Plus Summary of Benefits
- BlueCare Plus Choice Summary of Benefits
- BlueCare Plus Member Handbook
- BlueCare Plus Choice Member Handbook
- BlueCare Plus Evidence of Coverage
- BlueCare Plus Choice Evidence of Coverage
- BlueCare Plus PCP Change Form
- Request Your Plan Materials
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.
- Medicare with Medicaid (BlueCare Plus) Medication List (Formulary)
- Pharmacy Directory
- Prescription Claim Form
- Click here to fill out the Prescription Coverage Determination form online
- Request for Prescription Coverage Determination Form
- Click here to fill out the Prescription Redetermination form online
- Request for Prescription Redetermination Form
- Prescription Home Delivery Form
- Part D Out of Network Coverage
- Prior Authorization Criteria
- Quality Assurance Policies and Procedures
- Transition Policies and Procedures
- Over-the-Counter Catalog
- Over-the-Counter Order Form
- One Touch® Free Blood Glucose Monitor Voucher
- Ascensia® Contour Free Blood Glucose Monitor Voucher
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 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.