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℠)
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.
- 2022 BlueAdvantage Diamond Middle/West Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Diamond Northeast Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Diamond Southeast Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Ruby Middle Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Ruby Northeast Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Ruby Southeast Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Ruby West Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Sapphire Southeast Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Sapphire East Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Sapphire Northeast Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Garnet Middle Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Garnet West Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Emerald Middle Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Emerald Northeast Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Emerald Southeast Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Emerald West Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Freedom Evidence of Coverage (Updated: 9/1/2021)
- 2022 BlueAdvantage Summary of Benefits Northeast - Diamond, Ruby, Emerald (Updated: 8/1/2021)
- 2022 BlueAdvantage Summary of Benefits Southeast - Diamond, Ruby, Emerald (Updated: 8/1/2021)
- 2022 BlueAdvantage Summary of Benefits Middle and West - Diamond, Ruby, Emerald (Updated: 8/1/2021)
- 2022 BlueAdvantage Summary of Benefits Middle and West - Garnet (Updated: 8/1/2021)
- 2022 BlueAdvantage Summary of Benefits Southeast and East - Sapphire (Updated: 8/1/2021)
- 2022 BlueAdvantage Summary of Benefits Northeast - Sapphire (Updated: 8/1/2021)
- 2022 BlueAdvantage Summary of Benefits Freedom (Updated: 8/1/2021)
Use this form if you'd like BlueCross to accept bank draft payments.
These documents contain information about your benefits, network and 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.
- 2022 Medicare Advantage (BlueAdvantage) Medication List (Formulary) (Updated: 7/1/2022)
- 2022 Prior Authorization Criteria (Updated: 7/1/2022)
- 2022 Pharmacy Directory
- Prescription Claim Form
- Click here to fill out the Prescription Coverage Determination form online
- Request for Prescription Coverage Determination Form (Updated: 1/1/2020)
- Click here to fill out the Prescription Redetermination form online
- Request for Prescription Redetermination Form (Updated: 7/1/2020)
- Prescription Home Delivery Form
- Part D Out of Network Coverage
- Quality Assurance Policies and Procedures
- Transition Policies and Procedures
- One Touch® Free Blood Glucose Monitor Voucher
- Ascensia® Contour Free Blood Glucose Monitor Voucher
- Blank medication List
- Drug Disposal Information
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.
- 2022 Diamond Northeast Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Diamond Southeast Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Diamond Middle/West Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Ruby Northeast Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Ruby Southeast Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Ruby Middle Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Ruby West Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Sapphire Northeast Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Sapphire Southeast Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Sapphire East Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Garnet West Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Garnet Middle Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Emerald Northeast Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Emerald Southeast Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Emerald Middle Annual Notice of Changes (Updated: 8/1/2021)
- 2022 Emerald West Annual Notice of Changes (Updated: 8/1/2021)