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.

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.


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.

Summary of Benefits

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

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.