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 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.
- 2022 BlueCare Plus Plan Rating (Updated: 10/1/2021)
- 2022 BlueCare Plus Summary of Benefits (Updated: 8/1/2021)
- 2022 BlueCare Plus Choice Summary of Benefits (Updated: 8/1/2021)
- 2022 BlueCare Plus Benefits Booklet
- 2022 BlueCare Plus Choice Benefits Booklet
- 2022 BlueCare Plus Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueCare Plus Choice Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueCare Plus Dental Guide
- BlueCare Plus PCP Change Form
- Over-the-Counter Order Form
- Over-the-Counter and Healthy Foods FAQs
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.
- 2022 Medicare with Medicaid (BlueCare Plus) Medication List (Formulary) (Updated: 6/1/2022)
- 2022 Prior Authorization Criteria (Updated: 6/1/2022)
- Prescription Claim Form
- Request for Prescription Coverage Determination Form (Updated: 1/1/2020)
- Request for Prescription Redetermination Form (Updated: 7/1/2020)
- Prescription Home Delivery Form
- Part D Out of Network Coverage
- Quality Assurance Policies and Procedures
- Transition Policies and Procedures
- One Touch® Free Blood Glucose Monitor Voucher
- Ascensia® Contour Free Blood Glucose Monitor Voucher
- Blank medication List
- Drug Disposal Information
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.
- 2022 BlueCare Plus Annual Notice of Changes (Updated: 8/1/2021)
- 2022 BlueCare Plus Choice Annual Notice of Changes (Updated: 8/1/2021)