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
2025 Medex®´ Outline of Coverage Updated 10/01/2024
2024 Medex®´ Freedom of Choice Brochure Updated 10/01/2023
2025 Medex®´ Freedom of Choice Brochure Updated 10/01/2024
2024 Medicare HMO Blue Summary of Benefits Updated 10/01/2023
2025 Medicare HMO Blue Summary of Benefits Updated 10/01/2024
2024 Medicare PPO Blue Summary of Benefits Updated 10/01/2023
2025 Medicare PPO Blue Summary of Benefits Updated 10/01/2024
2024 Blue MedicareRx Summary of Benefits Updated 10/01/2023
2025 Blue MedicareRx Summary of Benefits Updated 10/01/2024
2024 Blue MedicareRx Sales Brochure Updated 10/01/2023
2025 Blue MedicareRx Sales Brochure Updated 10/01/2024
2024 Dental Blue®´ 65 Outline of Coverage Updated 10/01/2023
2025 Dental Blue®´ 65 Outline of Coverage Updated 10/01/2024
Evidence of Coverage (EOC)
2024 Medicare HMO Blue SaverRx EOC Updated 10/01/2023
2025 Medicare HMO Blue SaverRx EOC Updated 10/01/2024
2024 Medicare HMO Blue ValueRx EOC Updated 10/01/2023
2025 Medicare HMO Blue ValueRx EOC Updated 10/01/2024
2024 Medicare HMO Blue FlexRx EOC Updated 10/01/2023
2025 Medicare HMO Blue FlexRx EOC Updated 10/01/2024
2024 Medicare HMO Blue PlusRx EOC Updated 10/01/2023
2025 Medicare HMO Blue PlusRx EOC Updated 10/01/2024
2024 Medicare PPO Blue SaverRx EOC Updated 10/01/2023
2025 Medicare PPO Blue SaverRx EOC Updated 10/01/2024
2024 Medicare PPO Blue ValueRx EOC Updated 10/01/2023
2025 Medicare PPO Blue ValueRx EOC Updated 10/01/2024
2024 Medicare PPO Blue PlusRx EOC Updated 10/01/2023
2025 Medicare PPO Blue PlusRx EOC Updated 10/01/2024
Annual Notice of Changes (ANOC)
2024 Medicare HMO Blue SaverRx ANOC - All Counties Updated 10/01/2023
2025 Medicare HMO Blue SaverRx ANOC - All Counties Updated 10/01/2024
2024 Medicare HMO Blue ValueRx ANOC – Worcester County Updated 10/01/2023
2025 Medicare HMO Blue ValueRx ANOC – Worcester County Updated 10/01/2024
2024 Medicare HMO Blue Value Rx ANOC – Non-Worcester Counties Updated 10/01/2023
2025 Medicare HMO Blue Value Rx ANOC – Non-Worcester Counties Updated 10/01/2024
2024 Medicare HMO Blue FlexRx ANOC – Worcester County Updated 10/01/2023
2025 Medicare HMO Blue FlexRx ANOC – Worcester County Updated 10/01/2024
2024 Medicare HMO Blue FlexRx ANOC – Non-Worcester Counties Updated 10/01/2023
2025 Medicare HMO Blue FlexRx ANOC – Non-Worcester Counties Updated 10/01/2024
2024 Medicare HMO Blue PlusRx ANOC - All Counties Updated 10/01/2023
2025 Medicare HMO Blue PlusRx ANOC - All Counties Updated 10/01/2024
2024 Medicare PPO Blue SaverRx ANOC - All Counties Updated 10/01/2023
2025 Medicare PPO Blue SaverRx ANOC - All Counties Updated 10/01/2024
2024 Medicare PPO ValueRx ANOC – Worcester County Updated 10/01/2023
2025 Medicare PPO ValueRx ANOC – Worcester County Updated 10/01/2024
2024 Medicare PPO Blue ValueRx ANOC – Non-Worcester Counties Updated 10/01/2023
2025 Medicare PPO Blue ValueRx ANOC – Non-Worcester Counties Updated 10/01/2024
2024 Medicare PPO Blue PlusRx ANOC - All Counties Updated 10/01/2023
2025 Medicare PPO Blue PlusRx ANOC - All Counties Updated 10/01/2024
Enrollment Applications
2024 Medex®´ Enrollment Form Updated 10/01/2023
2025 Medex®´ Enrollment Form Updated 10/01/2024
2024 Medicare HMO Blue Enrollment Form Updated 10/01/2023
2025 Medicare HMO Blue Enrollment Form Updated 10/01/2024
2024 Medicare PPO Blue Enrollment Form Updated 10/01/2023
2025 Medicare PPO Blue Enrollment Form Updated 10/01/2024
2024 Blue MedicareRx Enrollment Form Updated 10/01/2023
2025 Blue MedicareRx Enrollment Form Updated 10/01/2024
2024 Dental Blue®´ 65 Enrollment Form Updated 10/01/2023
2025 Dental Blue®´ 65 Enrollment Form Updated 10/01/2024
Medicare Advantage
2024 Flex Card Purchase Reimbursement Form Effective 01/01/2024
2025 Flex Card Purchase Reimbursement Form Effective 10/01/2024
2025 In-Home Support Directory Updated 10/01/2024
2024 Medicare Advantage Part B Step Therapy Program Drug List Effective 05/01/2024
2025 Medicare Advantage Part B Step Therapy Program Drug List Effective 10/01/2024
2024 LIS Premium Summary Chart Updated 10/01/2023
2025 LIS Premium Summary Chart Updated 10/01/2024
2024 Medicare HMO Blue Star Rating Updated 10/19/2023
2025 Medicare HMO Blue Star Rating Updated 10/10/2024
2024 Medicare PPO Blue Star Rating Updated 10/19/2023
2025 Medicare PPO Blue Star Rating Updated 10/10/2024
2024 Over-the-Counter Catalog Updated 11/01/2023
2025 Over-the-Counter Catalog Updated 10/01/2024
2024 Over-the-Counter Catalog (Spanish) Updated 11/01/2023
2025 Over-the-Counter Catalog (Spanish) Updated 10/01/2024
Medicare Advantage Subscriber Claim Form Updated 10/01/2023
Appointment of a Representative Form (CMS Version) Updated 10/01/2024
Medicare Advantage Payment Options Updated 10/01/2023
Pre-Certification / Pre-Authorization Request Form Updated 10/01/2023
Continuity of Care Form Updated 12/01/2023
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 List of Medicare Advantage Network Pharmacies Updated on 10/01/2023
2025 List of Medicare Advantage Network Pharmacies Updated on 10/01/2024
2024 Medicare HMO Blue Formulary Updated on 11/01/2024
2025 Medicare HMO Blue Formulary Updated on 10/01/2024
2024 Medicare PPO Blue Formulary Updated on 11/01/2024
2025 Medicare PPO Blue Formulary Updated on 10/01/2024
2024 Medicare Advantage Group 3-Tier Formulary Updated on 11/01/2024
2025 Medicare Advantage Group 3-Tier Formulary Updated on 10/01/2024
2024 Medicare Advantage Group 2-Tier Formulary Updated on 11/01/2024
2025 Medicare Advantage Group 2-Tier Formulary Updated on 10/01/2024
2024 Medicare Advantage Prior Authorization Criteria Updated on 11/01/2024
2025 Medicare Advantage Prior Authorization Criteria Updated on 10/01/2024
2024 Medicare Advantage Step Therapy Criteria Updated on 08/01/2024
2025 Medicare Advantage Step Therapy Criteria Updated on 10/01/2024
Medicare Advantage Prescription Claim Form Updated on 10/01/2023
Request for Medicare Prescription Drug Coverage Determination Updated on 10/01/2023
Prior Authorization Request Form Updated on 4/01/2024
Request for Redetermination of Medicare Prescription Drug Denial Updated on 10/01/2023
Medicare Advantage Vaccine Claim Form Updated on 10/01/2023
Reimbursement Forms
2024 Flex Card Purchase Reimbursement Form Effective 01/01/2024
2025 Flex Card Purchase Reimbursement Form Effective 10/01/2024
2024 Medex®´ Fitness Benefit Form Updated on 10/01/2023
2025 Medex®´ Fitness Benefit Form Updated on 10/01/2024
2024 Medex®´Weight Loss Benefit Form Updated on 10/01/2023
2025 Medex®´Weight Loss Benefit Form Updated on 10/01/2024
EyeMed®´´ Claims Form Updated on 10/01/2023
Medex
Medex Subscriber Claim Form Updated 10/01/2024
Medex Payment Options Updated 10/01/2023
Medex Prescription Claim Form Updated 10/01/2023
Blue Cross Blue Shield Global Core Brochure Updated 10/01/2023
Blue Cross Blue Shield Global Core Claim Form Updated 10/01/2023
Managed Blue for Seniors
Weight Loss Form Updated 10/01/2023
Fitness Form Updated 10/01/2023
Medical Claim Form Updated 10/01/2022
Enhanced Dental Benefits
2024 Enhanced Dental Benefits Fact Sheet Updated 10/01/2023
2025 Enhanced Dental Benefits Fact Sheet Updated 10/01/2024
Enhanced Dental Benefits Enrollment Form Updated 10/01/2023
Privacy, Nondiscrimination, and Translation Resources
Commitment to Confidentiality Updated 10/01/2023
Nondiscrimination Disclosure and Language Translation Services Updated 10/01/2023
Deceased Member Affidavit
Deceased Member Affidavit Updated 10/01/2023
Healthy Times Newsletter
Download the current issue of our quarterly newsletter for helpful health and wellness information.
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.
