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℠)
The Annual Notice of Change describes the changes to your plan's costs and benefits from the previous year.
- 2025 BlueCare Plus Annual Notice of Changes (Updated: 10/1/24)
- 2025 BlueCare Plus Choice Annual Notice of Changes (Updated: 10/1/24)
- 2025 BlueCare Plus Select Annual Notice of Changes (Updated: 10/1/24)
These documents contain information about your benefits, network and coverage.
- 2025 BlueCare Plus Member Handbook
- 2025 BlueCare Plus Choice Member Handbook
- 2025 BlueCare Select Member Handbook
- 2025 BlueCare Plus Dental Guide (Updated: 10/1/2024)
- 2025 BlueCare Plus Plan Rating (Updated: 10/22/2024)
- Over-the-Counter (OTC) Online Catalog/Flex Card Website
- BlueCare Plus PCP Change Form
- Find Care
Additional Resources
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.
- 2025 BlueCare Plus Tennessee Enrollment Form
- 2025 BlueCare Plus Low Income Subsidy Table (Medicaid Eligible)
- 2025 BlueCare Plus Select Low Income Subsidy Table
- 2025 BlueCare Plus Choice Low Income Subsidy Table (Medicaid Eligible)
- 2025 BlueCare Plus Choice Low Income Subsidy Table (Non-Medicaid Eligible)
Download a complete list of your plan's coverage, cost and benefits, also called your Evidence of Coverage.
- 2025 BlueCare Plus Evidence of Coverage (Updated: 10/1/24)
- 2025 BlueCare Plus Choice Evidence of Coverage (Updated: 10/1/24)
- 2025 BlueCare Plus Select Evidence of Coverage (Updated: 10/1/24)
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.
- 2025 BlueCare Plus Tennessee Medication List (Formulary) (Updated 5/1/2025)
- 2025 Medicare Part D Prior Authorization Criteria (Updated 5/1/2025)
- Medicare Part B Prior Authorization Criteria
- Part B Step Therapy Guide
- Blank medication List
- Drug Disposal Information (Updated: 1/1/2020)
- Free Contour Blood Glucose Monitor Coupon
- Medicare Prescription Payment Plan Election Form (Updated: 10/1/2024)
- Medicare Prescription Payment Plan Fact Sheet (Updated: 10/1/2024)
- Medicare Prescription Payment Plan Terms & Conditions (Updated: 10/1/2024)
- OneTouch® Free Blood Glucose Monitor Voucher
- Part D Out of Network Coverage
- Pharmacy Directory
- Prescription Claim Form
- Prescription Home Delivery Form
- Provider Administered Specialty Drug List (Updated 5/1/2025)
- Provider-Administered Medication Authorization Form
- Quality Assurance Policies and Procedures
- Request for Prescription Coverage Determination Form (Updated: 1/1/2020)
- Click here to fill out the Prescription Coverage Determination form online
- Request for Prescription Redetermination (Updated: 7/1/2020)
- Click here to fill out the Prescription Redetermination form online
- Transition Policies and Procedures
Download a simplified list of your plan's benefits and coverage, also called the Summary of Benefits.
- 2025 BlueCare Plus Summary of Benefits (Updated: 10/1/24)
- 2025 BlueCare Plus Choice Summary of Benefits (Updated: 10/1/24)
- 2025 BlueCare Plus Select Summary of Benefits (Updated: 10/1/24)
Use these resources to help you get the care you need and stay well.
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.