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 Advantage (BlueEssential)
- Medicare Supplement (BlueElite)
- Medicare with Medicaid (BlueCare Plus℠)
Medicare Advantage (BlueAdvantage)
Not sure if this is your plan? Medicare Advantage includes BlueAdvantage
SM Diamond, Ruby, Garnet and Sapphire which should be listed on your Membership ID card.
Use these resources to help you enroll in a plan.
Use this form if you'd like BlueCross to accept bank draft payments.
These documents contain information about your benefits, network and coverage.
- BlueAdvantage Plan Rating
- Medicare 101 Guide
- Request Your Plan Materials
- Find a Doctor
- Prior Authorization Form
- BlueAdvantage Summary of Benefits Northeast - Diamond, Ruby, Emerald
- BlueAdvantage Summary of Benefits Southeast - Diamond, Ruby, Emerald
- BlueAdvantage Summary of Benefits Middle and West - Diamond, Ruby, Emerald
- BlueAdvantage Summary of Benefits Middle and West - Garnet
- BlueAdvantage Summary of Benefits Southeast - Sapphire
- BlueAdvantage Summary of Benefits Northeast - Sapphire
- BlueAdvantage Diamond Middle/West Evidence of Coverage
- BlueAdvantage Diamond Northeast Evidence of Coverage
- BlueAdvantage Diamond Southeast Evidence of Coverage
- BlueAdvantage Ruby Middle Evidence of Coverage
- BlueAdvantage Ruby Northeast Evidence of Coverage
- BlueAdvantage Ruby Southeast Evidence of Coverage
- BlueAdvantage Ruby West Evidence of Coverage
- BlueAdvantage Sapphire Southeast Evidence of Coverage
- BlueAdvantage Sapphire Northeast Evidence of Coverage
- BlueAdvantage Garnet Middle Evidence of Coverage
- BlueAdvantage Garnet West Evidence of Coverage
- BlueAdvantage Emerald Middle Evidence of Coverage
- BlueAdvantage Emerald Northeast Evidence of Coverage
- BlueAdvantage Emerald Southeast Evidence of Coverage
- BlueAdvantage Emerald West Evidence of Coverage
Summary of Benefits
Evidence of Coverage
Use these forms to file an appeal about coverage or payment decision, or to file a grievance if you have concerns about your plan, providers or quality of care.
These documents offer information about your covered drug benefits.
- 2021 Medicare Advantage (BlueAdvantage) Medication List (Formulary)
- 2020 Medicare Advantage (BlueAdvantage) Medication List (Formulary)
- Pharmacy Directory
- Prescription Claim Form
- Click here to fill out the Prescription Coverage Determination form online
- Request for Prescription Coverage Determination Form
- Click here to fill out the Prescription Redetermination form online
- Request for Prescription Redetermination Form
- Prescription Home Delivery Form
- Part D Out of Network Coverage
- Prior Authorization Criteria
- 2021 Prior Authorization Criteria
- Quality Assurance Policies and Procedures
- Transition Policies and Procedures
- One Touch® Free Blood Glucose Monitor Voucher
- Ascensia® Contour Free Blood Glucose Monitor Voucher
You'll find notices and forms in this section to help you understand your rights and responsibilities, and make requests related to those rights.
-
Request Personal Representative Form
Use this form to give someone permission to talk with us about your benefits.
-
Appointment of Representative Form
Use this form to let someone represent you for a claim, appeal or grievance for your Medicare Advantage
plan.
- Notice of Privacy Practices
- Request Interpreter Services in Another Language
The Annual Notice of Changes describes the changes to your plan’s costs and benefits from the previous year.
- Diamond Northeast Annual Notice of Changes
- Diamond Southeast Annual Notice of Changes
- Diamond Middle/West Annual Notice of Changes
- Diamond West Annual Notice of Changes
- Ruby Northeast Annual Notice of Changes
- Ruby Southeast Annual Notice of Changes
- Ruby Middle Annual Notice of Changes
- Ruby West Annual Notice of Changes
- Sapphire Northeast Annual Notice of Changes
- Sapphire Southeast Annual Notice of Changes
- Garnet West Annual Notice of Changes
- Garnet Middle Annual Notice of Changes
- Emerald Northeast Annual Notice of Changes
- Emerald Southeast Annual Notice of Changes
- Emerald Middle Annual Notice of Changes
- Emerald West Annual Notice of Changes