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℠)
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Medicare Advantage (BlueAdvantage)
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.
Enrollment
Use these resources to help you enroll in a plan.
Billing
Use this form if you'd like BlueCross to accept bank draft payments.
Benefits & Coverage
These documents contain information about your benefits, network and coverage.
- 2020 BlueAdvantage Plan Rating
- Medicare 101 Guide
- Request Your Plan Materials
- Find a Doctor
- Prior Authorization Form
- 2021 BlueAdvantage Summary of Benefits Northeast - Diamond, Ruby, Emerald
- 2021 BlueAdvantage Summary of Benefits Southeast - Diamond, Ruby, Emerald
- 2021 BlueAdvantage Summary of Benefits Middle and West - Diamond, Ruby, Emerald
- 2021 BlueAdvantage Summary of Benefits Middle and West - Garnet
- 2021 BlueAdvantage Summary of Benefits Southeast - Sapphire
- 2021 BlueAdvantage Summary of Benefits Northeast - Sapphire
- 2020 BlueAdvantage Summary of Benefits Northeast - Diamond, Ruby, Emerald
- 2020 BlueAdvantage Summary of Benefits Southeast - Diamond, Ruby, Emerald
- 2020 BlueAdvantage Summary of Benefits Middle and West - Diamond, Ruby, Emerald
- 2020 BlueAdvantage Summary of Benefits Middle and West - Garnet
- 2020 BlueAdvantage Summary of Benefits Southeast - Sapphire
- 2020 BlueAdvantage Summary of Benefits Northeast - Sapphire
- 2021 BlueAdvantage Diamond Middle/West Evidence of Coverage
- 2021 BlueAdvantage Diamond Northeast Evidence of Coverage
- 2021 BlueAdvantage Diamond Southeast Evidence of Coverage
- 2021 BlueAdvantage Ruby Middle Evidence of Coverage
- 2021 BlueAdvantage Ruby Northeast Evidence of Coverage
- 2021 BlueAdvantage Ruby Southeast Evidence of Coverage
- 2021 BlueAdvantage Ruby West Evidence of Coverage
- 2021 BlueAdvantage Sapphire Southeast Evidence of Coverage
- 2021 BlueAdvantage Sapphire Northeast Evidence of Coverage
- 2021 BlueAdvantage Garnet Middle Evidence of Coverage
- 2021 BlueAdvantage Garnet West Evidence of Coverage
- 2021 BlueAdvantage Emerald Middle Evidence of Coverage
- 2021 BlueAdvantage Emerald Northeast Evidence of Coverage
- 2021 BlueAdvantage Emerald Southeast Evidence of Coverage
- 2021 BlueAdvantage Emerald West Evidence of Coverage
- 2020 BlueAdvantage Diamond Middle Evidence of Coverage
- 2020 BlueAdvantage Diamond Northeast Evidence of Coverage
- 2020 BlueAdvantage Diamond Southeast Evidence of Coverage
- 2020 BlueAdvantage Diamond West Evidence of Coverage
- 2020 BlueAdvantage Ruby Middle Evidence of Coverage
- 2020 BlueAdvantage Ruby Northeast Evidence of Coverage
- 2020 BlueAdvantage Ruby Southeast Evidence of Coverage
- 2020 BlueAdvantage Ruby West Evidence of Coverage
- 2020 BlueAdvantage Sapphire Southeast Evidence of Coverage
- 2020 BlueAdvantage Sapphire Northeast Evidence of Coverage
- 2020 BlueAdvantage Garnet Middle Evidence of Coverage
- 2020 BlueAdvantage Garnet West Evidence of Coverage
- 2020 BlueAdvantage Emerald Middle Evidence of Coverage
- 2020 BlueAdvantage Emerald Northeast Evidence of Coverage
- 2020 BlueAdvantage Emerald Southeast Evidence of Coverage
- 2020 BlueAdvantage Emerald West Evidence of Coverage
Summary of Benefits
2021
2020
Evidence of Coverage
2021
2020
Grievances & Appeals
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.
Pharmacies & Prescriptions
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
- Step Therapy Criteria
- Quality Assurance Policies and Procedures
- Transition Policies and Procedures
- One Touch® Free Blood Glucose Monitor Voucher
- Ascensia® Contour Free Blood Glucose Monitor Voucher
Your Rights
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
Annual Notice of Changes
The Annual Notice of Changes describes the changes to your plan’s costs and benefits from the previous year.
- 2021 Diamond Northeast Annual Notice of Changes
- 2021 Diamond Southeast Annual Notice of Changes
- 2021 Diamond Middle/West Annual Notice of Changes
- 2021 Diamond West Annual Notice of Changes
- 2021 Ruby Northeast Annual Notice of Changes
- 2021 Ruby Southeast Annual Notice of Changes
- 2021 Ruby Middle Annual Notice of Changes
- 2021 Ruby West Annual Notice of Changes
- 2021 Sapphire Northeast Annual Notice of Changes
- 2021 Sapphire Southeast Annual Notice of Changes
- 2021 Garnet West Annual Notice of Changes
- 2021 Garnet Middle Annual Notice of Changes
- 2021 Emerald Northeast Annual Notice of Changes
- 2021 Emerald Southeast Annual Notice of Changes
- 2021 Emerald Middle Annual Notice of Changes
- 2021 Emerald West Annual Notice of Changes
- 2020 Diamond Northeast Annual Notice of Changes
- 2020 Diamond Southeast Annual Notice of Changes
- 2020 Diamond Middle Annual Notice of Changes
- 2020 Diamond West Annual Notice of Changes
- 2020 Ruby Northeast Annual Notice of Changes
- 2020 Ruby Southeast Annual Notice of Changes
- 2020 Ruby Middle Annual Notice of Changes
- 2020 Ruby West Annual Notice of Changes
- 2020 Sapphire Northeast Annual Notice of Changes
- 2020 Sapphire Southeast Annual Notice of Changes
- 2020 Garnet West Annual Notice of Changes
- 2020 Garnet Middle Annual Notice of Changes
2021
2020