Important Forms and Documents

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2017 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 BlueAccess to get your important forms and documents.


 

BlueAdvantage (PPO) Forms and Documents

CategoryLinks

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

 

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

Formulary
The formulary 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.

Evidence of Coverage (EOC)

 

The Evidence of Coverage describes your Medicare health benefits, services and prescription drug coverage as a member of our plan.

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

 

BlueChoice (HMO) Forms and Documents

CategoryLinks

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

Formulary
The formulary 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.

Evidence of Coverage (EOC)

 

The Evidence of Coverage describes your Medicare health benefits, services and prescription drug coverage as a member of our plan.

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

CategoryLinks

Plan Information

Pharmacy

If you are a BlueElite member and do not have a Part D prescription drug plan, you can get special access to our Discount Drug Card Program. This program gives you discounts at participating pharmacies. Just present your BlueElite Member ID card when you have prescriptions filled at participating pharmacies. For more information or to find a pharmacy near you, please call member service at 1-800-553-8158.

Important Forms

Outline of Coverage (OOC)

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.

Vouchers and Coupons

 

BlueCare Plus (HMO SNP)

CategoryLinks

Plan Information

Please visit bluecareplus.bcbst.com for plan information, forms and documents.

Prior Authorization Forms

Out-of-network/non-contracted providers are under no obligation to treat BlueAdvantage members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our member service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

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