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.
The Annual Notice of Changes describes the changes to your plan’s costs and benefits from the previous year.
- 2025 Diamond Middle/West Annual Notice of Changes (Updated: 10/1/2024)
- 2025 Diamond Northeast Annual Notice of Changes (Updated: 10/1/2024)
- 2025 Diamond Southeast Annual Notice of Changes (Updated: 10/1/2024)
- 2025 Extra Annual Notice of Changes (Updated: 10/1/2024)
- 2025 Freedom Annual Notice of Changes (Updated: 10/1/2024)
- 2025 Garnet Middle Annual Notice of Changes (Updated: 10/1/2024)
- 2025 Garnet West Annual Notice of Changes (Updated: 10/1/2024)
- 2025 North Georgia Annual Notice of Changes (Updated: 10/1/2024)
- 2025 Ruby Middle Annual Notice of Changes (Updated: 10/1/2024)
- 2025 Ruby Northeast Annual Notice of Changes (Updated: 10/1/2024)
- 2025 Ruby Southeast Annual Notice of Changes (Updated: 10/1/2024)
- 2025 Ruby West Annual Notice of Changes (Updated: 10/1/2024)
- 2025 Sapphire East Annual Notice of Changes (Updated: 10/1/2024)
- 2025 Sapphire Northeast Annual Notice of Changes (Updated: 10/1/2024)
- 2025 Sapphire Southeast Annual Notice of Changes (Updated: 10/1/2024)
- BlueAdvantage Emerald Middle Non-Renewal Notice
- BlueAdvantage Emerald Northeast Non-Renewal Notice
- BlueAdvantage Emerald Southeast Non-Renewal Notice
- BlueAdvantage Emerald West Non-Renewal Notice
- 2024 Diamond Middle/West Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Diamond Northeast Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Diamond Southeast Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Emerald Middle Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Emerald Northeast Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Emerald Southeast Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Emerald West Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Freedom Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Garnet Middle Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Garnet West Annual Notice of Changes (Updated: 10/1/2023)
- 2024 North Georgia Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Ruby Middle Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Ruby Northeast Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Ruby Southeast Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Ruby West Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Sapphire East Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Sapphire Northeast Annual Notice of Changes (Updated: 10/1/2023)
- 2024 Sapphire Southeast Annual Notice of Changes (Updated: 10/1/2023)
2025
2025 BlueAdvantage Emerald Notices of Non-Renewal
2024
These documents contain information about your benefits, network and coverage.
- 2024 BlueAdvantage Plan Rating (Updated: 10/24/2023)
- 2024 BlueAdvantage Freedom Plan Rating (Updated: 10/24/2023)
- BlueAdvantage Over-the-Counter Catalog
- Find a Doctor
- Medicare 101 Guide
- Prior Authorization Form
- Request Your Plan Materials
Use this form if you'd like BlueCross to accept bank draft payments.
Use this form if you'd like to submit a claim.
Use these resources to help you enroll in a plan.
Download a complete list of your plan's coverage, cost and benefits, also called your Evidence of Coverage.
- 2025 BlueAdvantage Diamond Middle/West Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Diamond Northeast Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Diamond Southeast Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Extra Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Freedom Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Garnet Middle Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Garnet West Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage North Georgia Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Prime East Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Prime West Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Ruby Middle Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Ruby Northeast Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Ruby Southeast Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Ruby West Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Sapphire East Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Sapphire Northeast Evidence of Coverage (Updated 10/1/2024)
- 2025 BlueAdvantage Sapphire Southeast Evidence of Coverage (Updated 10/1/2024)
- 2024 BlueAdvantage Diamond Middle/West Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Diamond Northeast Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Diamond Southeast Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Emerald Middle Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Emerald Northeast Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Emerald Southeast Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Emerald West Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Extra Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Freedom Evidence of Coverage (Updated 2/16/2024)
- 2024 BlueAdvantage Garnet Middle Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Garnet West Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage North Georgia Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Ruby Middle Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Ruby Northeast Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Ruby Southeast Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Ruby West Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Sapphire East Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Sapphire Northeast Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Sapphire Southeast Evidence of Coverage (Updated 10/1/2023)
- 2024 BlueAdvantage Diamond Middle/West Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Diamond Northeast Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Diamond Southeast Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Emerald Middle Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Emerald Northeast Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Emerald Southeast Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Emerald West Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Freedom Evidence of Coverage Errata (Updated 2/16/2024)
- 2024 BlueAdvantage Garnet Middle Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Garnet West Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage North Georgia Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Ruby Middle Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Ruby Northeast Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Ruby Southeast Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Ruby West Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Sapphire East Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Sapphire Northeast Evidence of Coverage Errata (Updated 11/21/2023)
- 2024 BlueAdvantage Sapphire Southeast Evidence of Coverage Errata (Updated 11/21/2023)
2025
2024
2024 Errata
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.
- 2025 Medicare Advantage (BlueAdvantage) Medication List (Formulary) (Updated: 10/1/2024)
- 2025 Medicare Advantage (BlueAdvantage Extra) Medication List (Formulary) (Updated: 10/1/2024)
- 2025 Medicare Prescription Payment Plan Election Form (Updated: 10/1/2024)
- Medicare Prescription Payment Plan Fact Sheet (Updated: 10/1/2024)
- Medicare Prescription Payment Plan Terms & Conditions (Updated: 10/1/2024)
- 2024 Medicare Advantage (BlueAdvantage) Medication List (Formulary) (Updated: 10/1/2024)
- 2024 Medicare Advantage (BlueAdvantage Extra) Medication List (Formulary) (Updated: 10/1/2024)
- 2024 Part B Step Therapy Reference Guide (Updated: 5/1/2024)
- 2024 Medicare Part D Prior Authorization Criteria (Updated: 10/1/2024)
- 2024 Medicare Part B Prior Authorization Criteria (Updated: 10/1/2024)
- Blank medication List
- Drug Disposal Information
- Find a Pharmacy (Pharmacy Directory)
- Free Contour Blood Glucose Monitor Coupon
- OneTouch Free Blood Glucose Monitor Voucher
- Part D Out of Network Coverage
- Prescription Claim Form
- Prescription Home Delivery Form
- Provider Administered Specialty Drug List (Updated: 10/1/2024)
- Provider-Administered Medication Authorization Form
- Quality Assurance Policies and Procedures
- Request for Prescription Coverage Determination Form (Updated: 1/1/2020)
- Click here to fill out the Prescription Coverage Determination form online
- Request for Prescription Redetermination Form (Updated: 7/1/2020)
- Click here to fill out the Prescription Redetermination form online
- Transition Policies and Procedures
Download a simplified list of your plan's benefits and coverage, also called the Summary of Benefits.
- 2025 BlueAdvantage Summary of Benefits Middle and West - Diamond, Ruby (Updated 10/1/2024)
- 2025 BlueAdvantage Summary of Benefits Northeast - Diamond, Ruby, Sapphire (Updated 10/1/2024)
- 2025 BlueAdvantage Summary of Benefits Southeast - Diamond, Ruby (Updated 10/1/2024)
- 2025 BlueAdvantage Summary of Benefits Extra (Updated 10/1/2024)
- 2025 BlueAdvantage Summary of Benefits Freedom (Updated 10/1/2024)
- 2025 BlueAdvantage Summary of Benefits Middle and West - Garnet (Updated 10/1/2024)
- 2025 BlueAdvantage Summary of Benefits North Georgia (Updated 10/1/2024)
- 2025 BlueAdvantage Summary of Benefits East - Prime (Updated 10/1/2024)
- 2025 BlueAdvantage Summary of Benefits West - Prime (Updated 10/1/2024)
- 2025 BlueAdvantage Summary of Benefits Southeast and East - Sapphire (Updated 10/1/2024)
- 2024 BlueAdvantage Summary of Benefits Middle and West - Diamond, Ruby, Emerald (Updated 10/1/2023)
- 2024 BlueAdvantage Summary of Benefits Northeast - Diamond, Ruby, Emerald (Updated 10/1/2023)
- 2024 BlueAdvantage Summary of Benefits Southeast - Diamond, Ruby, Emerald (Updated 12/15/2023)
- 2024 BlueAdvantage Summary of Benefits Extra (Updated 10/1/2023)
- 2024 BlueAdvantage Summary of Benefits Freedom (Updated 10/1/2023)
- 2024 BlueAdvantage Summary of Benefits Middle and West - Garnet (Updated 10/1/2023)
- 2024 BlueAdvantage Summary of Benefits North Georgia (Updated 10/1/2023)
- 2024 BlueAdvantage Summary of Benefits Northeast - Sapphire (Updated 10/1/2023)
- 2024 BlueAdvantage Summary of Benefits Southeast and East - Sapphire (Updated 10/1/2023)
2025
2024
You'll find notices and forms in this section to help you understand your rights and responsibilities, and make requests related to those rights.
- 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
- Request Personal Representative Form Use this form to give someone permission to talk with us about your benefits.