Online Forms & Plan Documents
Find everything you need in our collection of Massachusetts Medicare plan forms and documents.
Online Forms
Plan Documents
Designation of Representative
Summary of Benefits/Outlines of Coverage
2024 Medex®´ Outline of Coverage Updated 10/01/2023
2024 Medex®´ Freedom of Choice Brochure Updated 10/01/2023
2024 Medicare HMO Blue Summary of Benefits Updated 10/01/2023
2024 Medicare PPO Blue Summary of Benefits Updated 10/01/2023
2024 Blue MedicareRx Summary of Benefits Updated 10/01/2023
2024 Blue MedicareRx Sales Brochure Updated 10/01/2023
2024 Dental Blue®´ 65 Outline of Coverage Updated 10/01/2023
2023 Medex®´ Outline of Coverage Updated 10/01/2022
2023 Medex®´ Freedom of Choice Brochure Updated 10/01/2022
2023 Medicare HMO Blue Summary of Benefits Updated 10/01/2022
2023 Medicare PPO Blue Summary of Benefits Updated 10/01/2022
2023 Blue MedicareRx Summary of Benefits Updated 10/01/2022
2023 Blue MedicareRx Sales Brochure Updated 10/01/2022
2023 Dental Blue®´ 65 Outline of Coverage Updated 10/01/2022
Evidence of Coverage (EOC)
2024 Medicare HMO Blue SaverRx EOC Updated 10/01/2023
2024 Medicare HMO Blue ValueRx EOC Updated 10/01/2023
2024 Medicare HMO Blue FlexRx EOC Updated 10/01/2023
2024 Medicare HMO Blue PlusRx EOC Updated 10/01/2023
2024 Medicare PPO Blue SaverRx EOC Updated 10/01/2023
2024 Medicare PPO Blue ValueRx EOC Updated 10/01/2023
2024 Medicare PPO Blue PlusRx EOC Updated 10/01/2023
2023 Medicare HMO Blue SaverRx EOC Updated 10/01/2022
2023 Medicare HMO Blue ValueRx EOC Updated 10/01/2022
2023 Medicare HMO Blue FlexRx EOC Updated 10/01/2022
2023 Medicare HMO Blue PlusRx EOC Updated 10/01/2022
2023 Medicare PPO Blue SaverRx EOC Updated 10/01/2022
2023 Medicare PPO Blue ValueRx EOC Updated 10/01/2022
2023 Medicare PPO Blue PlusRx EOC Updated 10/01/2022
Part B IRA Change Notice Updated 03/01/2023
Annual Notice of Changes (ANOC)
2024 Medicare HMO Blue SaverRx ANOC - All Counties Updated 10/01/2023
2024 Medicare HMO Blue ValueRx ANOC – Worcester County Updated 10/01/2023
2024 Medicare HMO Blue Value Rx ANOC – Non-Worcester Counties Updated 10/01/2023
2024 Medicare HMO Blue FlexRx ANOC – Worcester County Updated 10/01/2023
2024 Medicare HMO Blue FlexRx ANOC – Non-Worcester Counties Updated 10/01/2023
2024 Medicare HMO Blue PlusRx ANOC - All Counties Updated 10/01/2023
2024 Medicare PPO Blue SaverRx ANOC - All Counties Updated 10/01/2023
2024 Medicare PPO ValueRx ANOC – Worcester County Updated 10/01/2023
2024 Medicare PPO Blue ValueRx ANOC – Non-Worcester Counties Updated 10/01/2023
2024 Medicare PPO Blue PlusRx ANOC - All Counties Updated 10/01/2023
Part B IRA Change Notice Updated 03/01/2023
2023 Medicare HMO Blue SaverRx ANOC - All Counties Updated 10/01/2022
2023 Medicare HMO Blue ValueRx ANOC – Worcester County Updated 10/01/2022
2023 Medicare HMO Blue Value Rx ANOC – Non-Worcester Counties Updated 10/01/2022
2023 Medicare HMO Blue FlexRx ANOC – Worcester County Updated 10/01/2022
2023 Medicare HMO Blue FlexRx ANOC – Non-Worcester Counties Updated 10/01/2022
2023 Medicare HMO Blue PlusRx ANOC - All Counties Updated 10/01/2022
2023 Medicare PPO Blue SaverRx ANOC - All Counties Updated 10/01/2022
2023 Medicare PPO ValueRx ANOC – Worcester County Updated 10/01/2022
2023 Medicare PPO Blue ValueRx ANOC – Non-Worcester Counties Updated 10/01/2022
2023 Medicare PPO Blue PlusRx ANOC - All Counties Updated 10/01/2022
Part B IRA Change Notice Updated 03/01/2022
Enrollment Applications
2024 Medex®´ Enrollment Form Updated 10/01/2023
2024 Medicare HMO Blue Enrollment Form Updated 10/01/2023
2024 Medicare PPO Blue Enrollment Form Updated 10/01/2023
2024 Blue MedicareRx Enrollment Form Updated 10/01/2023
2024 Dental Blue®´ 65 Enrollment Form Updated 10/01/2023
2023 Medex®´ Enrollment Form Updated 10/01/2022
2023 Medicare HMO Blue Enrollment Form Updated 10/01/2022
2023 Medicare PPO Blue Enrollment Form Updated 10/01/2022
2023 Blue MedicareRx Enrollment Form Updated 10/01/2022
2023 Dental Blue®´ 65 Enrollment Form Updated 10/01/2022
Medicare Advantage
2024 LIS Premium Summary Chart Updated 10/01/2023
2024 Medicare HMO Blue Star Rating Updated 10/19/2023
2024 Medicare PPO Blue Star Rating Updated 10/19/2023
2024 Medicare Advantage Subscriber Claim Form Updated 10/01/2023
2024 Appointment of a Representative Form (CMS Version) Updated 10/01/2023
2024 Medicare Advantage Payment Options Updated 10/01/2023
2024 Pre-Certification / Pre-Authorization Request Form Updated 10/01/2023
2024 Over-the-Counter Catalog Updated 11/01/2023
2023 LIS Premium Summary Chart Updated 10/01/2022
2023 Medicare HMO Blue Star Rating Updated 10/01/2022
2023 Medicare PPO Blue Star Rating Updated 10/01/2022
2023 Medicare Advantage Subscriber Claim Form Updated 10/01/2022
2023 Appointment of a Representative Form (CMS Version) Updated 10/01/2022
2023 Medicare Advantage Payment Options Updated 10/01/2022
2023 Pre-Certification / Pre-Authorization Request Form Updated 10/01/2022
Prescription Coverage
If you want a Provider directory, Pharmacy directory, and/or Formulary mailed to you, please call 1-800-200-4255 (TTY: 711), April 1 through September 30, 8:00 a.m. to 8:00 p.m., Monday through Friday, or October 1 through March 31, 8:00 a.m. to 8:00 p.m., seven days a week. You can also email your request to MMService@bcbsma.com.
2024 Medicare Advantage Prescription Claim Form Updated on 10/01/2023
2024 Mail Service Pharmacy Form Updated on 10/01/2023
2024 List of Medicare Advantage Network Pharmacies Updated on 10/01/2023
2024 Medicare HMO Blue Formulary Updated on 10/01/2023
2024 Medicare PPO Blue Formulary Updated on 10/01/2023
2024 Medicare Advantage Group 3-Tier Formulary Updated on 10/01/2023
2024 Medicare Advantage Group 2-Tier Formulary Updated on 10/01/2023
2024 Request for Medicare Prescription Drug Coverage Determination Updated on 10/01/2023
2024 Prior Authorization Request Form Updated on 10/01/2023
2024 Medicare Advantage Prior Authorization Criteria Updated on 10/11/2023
2024 Medicare Advantage Step Therapy Criteria Updated on 10/11/2023
2024 Request for Redetermination of Medicare Prescription Drug Denial Updated on 10/01/2023
2024 Medicare Advantage Vaccine Claim Form Updated on 10/01/2023
Medicare Advantage Prescription Claim Form Updated on 10/01/2022
Mail Service Pharmacy Form Updated on 10/01/2022
2023 List of Medicare Advantage Network Pharmacies Updated on 10/01/2022
2023 Medicare HMO Blue Formulary Updated on 11/01/2023
2023 Medicare PPO Blue Formulary Updated on 11/01/2023
2023 Medicare Advantage Group 3-Tier Formulary Updated on 11/01/2023
2023 Medicare Advantage Group 2-Tier Formulary Updated on 11/01/2023
2024 Request for Medicare Prescription Drug Coverage Determination Updated on 10/01/2022
2024 Prior Authorization Request Form Updated on 10/01/2022
2023 Medicare Advantage Prior Authorization Criteria Updated on 11/01/2023
2023 Medicare Advantage Step Therapy Criteria Updated on 11/01/2023
2023 Request for Redetermination of Medicare Prescription Drug Denial Updated on 10/01/2022
2023 Medicare Advantage Vaccine Claim Form Updated on 10/01/2022
Reimbursement Forms
2024 Medex®´ Fitness Benefit Form Updated on 10/01/2023
2024 Medex®´Weight-Loss Benefit Form Updated on 10/01/2023
2024 EyeMed®´´ Claims Form Updated on 10/01/2023
2023 Medex®´ Fitness Benefit FormUpdated on 10/01/2022
2023 Medex®´ Weight-Loss Benefit Form Updated on 10/01/2022
2023 Medicare Advantage Fitness Benefit Form Updated on 10/01/2022
2023 Medicare Advantage Weight-Loss Benefit Form Updated on 10/01/2022
2023 EyeMed®´´ Claims Form Updated on 10/01/2022
Medex
2024 Medex Subscriber Claim Form Updated 10/01/2023
2024 Medex Payment Options Updated 10/01/2023
2024 Medex Prescription Claim Form Updated 10/01/2023
2024 Blue Cross Blue Shield Global Core Brochure Updated 10/01/2023
2024 Blue Cross Blue Shield Global Core Claim Form Updated 10/01/2023
2023 Medex Subscriber Claim Form Updated 10/01/2022
2023 Medex Payment Options Updated 10/01/2022
2023 Medex Prescription Claim Form Updated 10/01/2022
2023 Blue Cross Blue Shield Global Core Brochure Updated 10/01/2022
2023 Blue Cross Blue Shield Global Core Claim Form Updated 10/01/2022
Managed Blue for Seniors
2024 Medical Claim Form Updated 10/01/2023
2024 Weight-Loss Form Updated 10/01/2023
2024 Fitness Form Updated 10/01/2023
2023 Medical Claim Form Updated 10/01/2022
2023 Weight-Loss Form Updated 10/01/2022
2023 Fitness Form Updated 10/01/2022
Enhanced Dental Benefits
2024 Enhanced Dental Benefits Fact Sheet Updated 10/01/2023
2024 Enhanced Dental Benefits Enrollment Form Updated 10/01/2023
2023 Enhanced Dental Benefits Fact Sheet Updated 10/01/2022
2023 Enhanced Dental Benefits Enrollment Form Updated 10/01/2022
Privacy, Nondiscrimination, and Translation Resources
2024 Commitment to Confidentiality Updated 10/01/2023
2024 Nondiscrimination Disclosure and Language Translation Services Updated 10/01/2023
2023 Commitment to Confidentiality Updated 10/01/2022
2023 Nondiscrimination Disclosure and Language Translation Services Updated 10/01/2022
Deceased Member Affidavit
2024 Deceased Member Affidavit Updated 10/01/2023
2023 Deceased Member Affidavit Updated 10/01/2022
Healthy Times Newsletter
Download the current issue of our quarterly newsletter for helpful health and wellness information.
2024 Healthy Times for Medicare Advantage members Updated 10/01/2023
2024 Healthy Times for Medex members Updated 10/01/2023
2023 Healthy Times for Medicare Advantage members Updated 10/01/2022
2023 Healthy Times for Medex members Updated 10/01/2022
To request that a printed provider directory, pharmacy directory, formulary, or Evidence of Coverage (EOC) be mailed to you, or if you need help finding these plan documents, please call Member Service at 1-800-200-4255 (TTY: 711) April 1 through September 30, 8:00 a.m. to 8:00 p.m. ET. Monday through Friday, or October 1 through March 31, 8:00 a.m. to 8:00 p.m. ET. seven days a week.