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.
Medicare Member Materials for 2024 will be available by 10/15/23. This includes Annual Notice of Coverage (ANOC), Evidence of Coverage (EOC), Summary of Benefits and Formularies.
- 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.
Use these resources to help you enroll in a plan.
- 2023 BlueAdvantage Diamond Middle/West Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Diamond Northeast Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Diamond Southeast Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Ruby Middle Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Ruby Northeast Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Ruby Southeast Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Ruby West Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Sapphire Southeast Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Sapphire East Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Sapphire Northeast Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Garnet Middle Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Garnet West Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Emerald Middle Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Emerald Northeast Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Emerald Southeast Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Emerald West Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage Freedom Evidence of Coverage (Updated 4/3/2023)
- 2023 BlueAdvantage North Georgia Evidence of Coverage (Updated 4/3/2023)
2023
- 2023 BlueAdvantage Summary of Benefits Northeast - Diamond, Ruby, Emerald (Updated 6/1/2023)
- 2023 BlueAdvantage Summary of Benefits Southeast - Diamond, Ruby, Emerald (Updated 6/1/2023)
- 2023 BlueAdvantage Summary of Benefits Middle and West - Diamond, Ruby, Emerald (Updated 6/1/2023)
- 2023 BlueAdvantage Summary of Benefits Middle and West - Garnet (Updated 6/1/2023)
- 2023 BlueAdvantage Summary of Benefits Southeast and East - Sapphire (Updated 6/1/2023)
- 2023 BlueAdvantage Summary of Benefits Northeast - Sapphire (Updated 6/1/2023)
- 2023 BlueAdvantage Summary of Benefits Freedom (Updated 6/1/2023)
- 2023 BlueAdvantage Summary of Benefits North Georgia (Updated 6/1/2023)
2023
Use this form if you'd like BlueCross to accept bank draft payments.
These documents contain information about your benefits, network and coverage.
- 2023 BlueAdvantage Plan Rating (Updated: 10/25/2022)
- 2023 BlueAdvantage Freedom Plan Rating (Updated: 10/25/2022)
- Medicare 101 Guide
- Request Your Plan Materials
- Find a Doctor
- Prior Authorization Form
- BlueAdvantage Over-the-Counter Catalog
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.
- 2023 Medicare Advantage (BlueAdvantage) Medication List (Formulary) (Updated: 9/1/2023)
- 2023 Prior Authorization Criteria (Updated: 9/1/2023)
- Find a Pharmacy (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
- Blank medication List
- Drug Disposal Information
- Free Contour Blood Glucose Monitor Coupon
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.
- 2023 Diamond Northeast Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Diamond Southeast Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Diamond Middle/West Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Ruby Northeast Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Ruby Southeast Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Ruby Middle Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Ruby West Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Sapphire Northeast Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Sapphire Southeast Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Sapphire East Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Garnet West Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Garnet Middle Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Emerald Northeast Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Emerald Southeast Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Emerald Middle Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Emerald West Annual Notice of Changes (Updated: 10/1/2022)
- 2023 Freedom Annual Notice of Changes (Updated: 10/1/2022)
2023