Designation of Representative
Medicare Advantage Member's Designation of a Personal Representative Form
Medex Member Designation of an Authorized Representative
Summary of Benefits/Outlines of Coverage
2022 Medex®' Outline of Coverage
2022 Medex Freedom of Choice Brochure
2022 Medicare HMO Blue Summary of Benefits Updated 10/01/2021
2022 Medicare PPO Blue Summary of Benefits Updated 10/01/2021
2022 Blue MedicareRx Summary of Benefits Updated 10/01/2021
2022 Blue MedicareRx Sales Brochure
2022 Dental Blue 65 Outline of Coverage
Evidence of Coverage (EOC)
2022 Medicare HMO Blue SaverRx EOC Updated 10/01/2021
2022 Medicare HMO Blue ValueRx EOC Updated 10/01/2021
2022 Medicare HMO Blue FlexRx EOC Updated 10/01/2021
2022 Medicare HMO Blue PlusRx EOC Updated 10/01/2021
2022 Medicare PPO Blue SaverRx EOC Updated 10/01/2021
2022 Medicare PPO Blue ValueRx EOC Updated 10/01/2021
2022 Medicare PPO Blue PlusRx EOC Updated 10/01/2021
Annual Notice of Changes (ANOC)
2022 Medicare HMO Blue SaverRx ANOC - All Counties Updated 10/01/2021
2022 Medicare HMO Blue ValueRx ANOC – Worcester County Updated 10/01/2021
2022 Medicare HMO Blue Value Rx ANOC – Non-Worcester Counties Updated 10/01/2021
2022 Medicare HMO Blue FlexRx ANOC – Worcester County Updated 10/01/2021
2022 Medicare HMO Blue FlexRx ANOC – Non-Worcester Counties Updated 10/01/2021
2022 Medicare HMO Blue PlusRx ANOC - All Counties Updated 10/01/2021
2022 Medicare PPO Blue SaverRx ANOC - All Counties Updated 10/01/2021
2022 Medicare PPO ValueRx ANOC – Worcester County Updated 10/01/2021
2022 Medicare PPO Blue ValueRx ANOC – Non-Worcester Counties Updated 10/01/2021
2022 Medicare PPO Blue PlusRx ANOC - All Counties Updated 10/01/2021
Enrollment Applications
2022 Medex Enrollment Form
2022 Medicare HMO Blue Enrollment Form
2022 Medicare PPO Blue Enrollment Form
2022 Blue MedicareRx Enrollment Form
2022 Dental Blue 65 Enrollment Form
Medicare Advantage
2022 LIS Premium Summary Chart
2022 Medicare HMO Blue Star Rating Updated 10/25/2021
2022 Medicare PPO Blue Star Rating Updated 10/25/2021
Medicare Advantage Subscriber Claim Form
Appointment of a Representative Form (CMS Version)
Medicare Advantage Payment Options
Pre-certification / Pre-Authorization Request Form Updated 10/01/2021
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.
Medicare Advantage Prescription Claim Form
Express Scripts Home Delivery Form
2022 List of Medicare Advantage Network Pharmacies
2022 Medicare HMO Blue Formulary
Updated 06/01/2022
2022 Medicare PPO Blue Formulary
Updated 06/01/2022
2022 Medicare Advantage Group 3-Tier Formulary
Updated 06/01/2022
2022 Medicare Advantage Group 2-Tier Formulary
Updated 06/01/2022
Request for Medicare Prescription Drug Coverage Determination
Prior Authorization Request Form
2022 Medicare Advantage Prior Authorization Criteria
Updated 06/01/2022
2022 Medicare Advantage Step Therapy Criteria
Updated 06/01/2022
Request for Redetermination of Medicare Prescription Drug Denial
Medicare Advantage Vaccine Claim Form
Reimbursement Forms
2022 Medex Fitness Benefit Form
2022 Medex Weight Loss Benefit Form
2022 Medicare Advantage Fitness Benefit Form
2022 Medicare Advantage Weight Loss Benefit Form
2022 EyeMed Claims Form
Medex
Medex Subscriber Claim Form
Medex Payment Options
Blue Cross Blue Shield Global Core Brochure
Blue Cross Blue Shield Global Core Claim Form
Enhanced Dental Benefits
Enhanced Dental Benefits Fact Sheet
Enhanced Dental Benefits Enrollment Form
Privacy, Nondiscrimination, and Translation Resources
Commitment to Confidentiality
Nondiscrimination Disclosure and Language Translation Services
Deceased Member Affidavit
Deceased Member Affidavit
Healthy Times Newsletter
Download the current issue of our quarterly newsletter for helpful health and wellness information.
Healthy Times for Medicare Advantage members
Healthy Times for Medex members