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.
- 2021 Enrollment Form
- 2021 BlueCare Plus Low Income Subsidy Table
- 2021 BlueCare Plus Choice Low Income Subsidy Table (Medicaid Eligible)
- 2021_BlueCare Plus Choice Low Income Subsidy Table (Non-Medicaid Eligible)
- 2020 Enrollment Form
- 2020 BlueCare Plus Low Income Subsidy Table
- 2020 BlueCare Plus Choice Low Income Subsidy Table (Medicaid Eligible)
- 2020 BlueCare Plus Choice Low Income Subsidy Table (Non-Medicaid Eligible)
2021
2020
These documents contain information about your benefits, network and coverage.
- BlueCare Plus PCP Change Form
- Request Your Plan Materials
- 2021 BlueCare Plus Plan Rating
- 2021 BlueCare Plus Summary of Benefits
- 2021 BlueCare Plus Choice Summary of Benefits
- 2021 BlueCare Plus Member Handbook
- 2021 BlueCare Plus Choice Member Handbook
- 2021 BlueCare Plus Evidence of Coverage
- 2021 BlueCare Plus Choice Evidence of Coverage
- 2020 BlueCare Plus Plan Rating
- 2020 BlueCare Plus Summary of Benefits
- 2020 BlueCare Plus Choice Summary of Benefits
- 2020 BlueCare Plus Member Handbook
- 2020 BlueCare Plus Choice Member Handbook
- 2020 BlueCare Plus Evidence of Coverage
- 2020 BlueCare Plus Choice Evidence of Coverage
2021
2020
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.
- 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
- 2021 Prior Authorization Criteria
- Step Therapy 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
- 2021 Medicare with Medicaid (BlueCare Plus) Medication List (Formulary)
- 2020 Medicare with Medicaid (BlueCare Plus) Medication List (Formulary)
2021
2020
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.