Important Forms and Documents

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2018 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.


BlueAdvantage (PPO) Forms and Documents

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Plan Information

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


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.


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

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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

Vouchers and Coupons


BlueCare Plus (HMO SNP)

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Plan Information

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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