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2020 Forms & Documents

Select your specific plan to view a list of printable forms and documents.

Looking for information about your group plan? Log on to BlueAccessSM to get your important forms and documents.

Our BlueAdvantage Plus (PPO) plan earned a 4-Star Rating for 2019.


 

BlueAdvantage (PPO) Forms and Documents

Category Links

Plan Information

The Summary of Benefits describes in detail what medical conditions and services will be covered, for what amounts and your financial responsibilities.

Directories

Out-of-State Coverage

If you are a BlueAdvantage member, you have coverage when you travel outside of Tennessee. The states and territory below participate in our shared PPO network:

 

Alabama, California, Colorado, Connecticut, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Missouri, Montana, North Carolina, Nevada, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Texas, Utah, Virginia, Washington, Wisconsin, West Virginia and Puerto Rico.

For some of the states listed, BlueAdvantage networks are only available in portions of the state.

 

When you seek routine care, you should use a network provider or it could cost you more.

 

All BlueCross BlueShield of Tennessee members have emergency coverage nationwide and worldwide.

Pharmacy

Prescription Drug List
The prescription drug list* is a comprehensive list of prescription drugs covered by your plan.


Other Pharmacy Forms and Documents

 

Important Forms

Grievances & Appeals 

You can file an appeal about coverage or payment decisions. File a grievance if you have concerns about your plan, providers or quality of care.

Annual Notice of Change (ANOC)

The Annual Notice of Change describes the changes to your plan’s costs and benefits from the previous year.

Vouchers and Coupons

 

BlueElite (Medicare Supplement) Forms and Documents

Category Links

Important Forms

The Accountable Alliance

Some BlueElite members may save money when they receive inpatient hospital care at a facility that participates in The Accountable Alliance.

To search for a participating facility, please go to usamco.com/bcbstn.

Coverage

Vouchers and Coupons


 

BlueCare Plus (HMO SNP)

Category Links

Plan Information

 

BlueEssential (HMO SNP) Forms and Documents

Category Links

Plan Information

The Summary of Benefits describes in detail what medical conditions and services will be covered, for what amounts and your financial responsibilities

Directories

Pharmacy

Prescription Drug List
The prescription drug list* is a comprehensive list of prescription drugs covered by your plan.


Other Pharmacy Forms and Documents

 

Important Forms

Grievances & Appeals 

You can file an appeal about coverage or payment decisions. File a grievance if you have concerns about your plan, providers or quality of care.

Vouchers and Coupons

Prior Authorization Forms

Out-of-network/non-contracted providers are under no obligation to treat BlueAdvantage members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

*Prescription drug lists change occasionally, but if that happens to a drug you're taking, we’ll provide you with written notice at least 30 days prior to the date when the change goes into effect. If you request a refill of the drug before this happens, we’ll provide written notice of the change and a 30-day supply under the same plan rules as before the change.

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