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 1-800-678-2265      TTY 711

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        • In-home Assessments for Chronically Ill Members
        • Enhanced Disease Management
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      • Fall Prevention
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      • Prescription Drug Utilization Review
    • Review Medical Claims
    • Discounts & Programs
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Plan Documents

Find everything you need in our collection of Massachusetts Medicare plan forms and documents.

Plan Documents Years
View document by plan year

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

2021 Medex®' Outline of Coverage

2021 Medex Freedom of Choice Brochure

2021 Medicare HMO Blue Summary of Benefits

2021 Medicare PPO Blue Summary of Benefits

2021 Blue MedicareRx Summary of Benefits

2021 Blue MedicareRx Sales Brochure

2021 Dental Blue 65 Outline of Coverage

Evidence of Coverage (EOC)

2021 Medicare HMO Blue SaverRx EOC

2021 Medicare HMO Blue ValueRx EOC

2021 Medicare HMO Blue FlexRx EOC

2021 Medicare HMO Blue PlusRx EOC

2021 Medicare PPO Blue SaverRx EOC

2021 Medicare PPO Blue ValueRx EOC

2021 Medicare PPO Blue PlusRx EOC

Annual Notice of Changes (ANOC)

2021 Medicare HMO Blue SaverRx ANOC - All Counties

2021 Medicare HMO Blue ValueRx ANOC – Worcester County

2021 Medicare HMO Blue Value Rx ANOC – Non-Worcester Counties

2021 Medicare HMO Blue FlexRx ANOC – Worcester County

2021 Medicare HMO Blue FlexRx ANOC – Non-Worcester Counties

2021 Medicare HMO Blue PlusRx ANOC - All Counties

2021 Medicare PPO Blue SaverRx ANOC - All Counties

2021 Medicare PPO ValueRx ANOC – Worcester County

2021 Medicare PPO Blue ValueRx ANOC – Non-Worcester Counties

2021 Medicare PPO Blue PlusRx ANOC - All Counties

Enrollment Applications

2021 Medex Enrollment Form

2021 Medicare HMO Blue Enrollment Form

2021 Medicare PPO Blue Enrollment Form

2021 Blue MedicareRx Enrollment Form

2021 Dental Blue 65 Enrollment Form

Medicare Advantage

2021 LIS Premium Summary Chart

2021 Medicare HMO Blue Star Rating

2021 Medicare PPO Blue Star Rating

Medicare Advantage Subscriber Claim Form

Appointment of a Representative Form (CMS Version)

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.

2021 Medicare Advantage Prescription Claim Form

Express Scripts Home Delivery Form 

2021 List of Medicare Advantage Network Pharmacies

2021 Medicare HMO/PPO Blue 5-Tier Formulary
Updated 02/01/2021

2021 Medicare HMO/PPO Blue 6-Tier Formulary
Updated 02/01/2021​​​​​​​

2021 Medicare Advantage Group Formulary
Updated 02/01/2021​​​​​​​

2021 Request for Medicare Prescription Drug Coverage Determination 

Prior Authorization Request Form

2021 Medicare Advantage Prior Authorization Criteria
Updated 02/01/2021​​​​​​​

2021 Medicare Advantage Step Therapy Criteria 
Updated 02/01/2021​​​​​​​

2021 Request for Redetermination of Medicare Prescription Drug Denial 

2021 Medicare Advantage Vaccine Claim Form

Fitness and Weight Loss Forms

2021 Medex Fitness Benefit Form

2021 Medex Weight Loss Benefit Form

2021 Medicare Advantage Fitness Benefit Form

2021 Medicare Advantage Weight Loss Benefit Form

Medex

Medex Subscriber Claim Form

Medex Payment Options

Privacy, Nondiscrimination, and Translation Resources

Commitment to Confidentiality

Nondiscrimination Disclosure

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

Designation of Representative

Medicare Advantage Member's Designation of a Personal Representative Form

Medicare Advantage Appointment of a Representative Form

Deceased Member Affidavit

Deceased Member Affidavit

Summary of Benefits/Outlines of Coverage

2021 Medex®' Outline of Coverage

2021 Medex Freedom of Choice Brochure

2021 Medicare HMO Blue Summary of Benefits

2021 Medicare PPO Blue Summary of Benefits

2021 Blue MedicareRx Summary of Benefits

2021 Blue MedicareRx Sales Brochure

2021 Dental Blue 65 Outline of Coverage

Evidence of Coverage (EOC)

2021 Medicare HMO Blue SaverRx EOC

2021 Medicare HMO Blue ValueRx EOC

2021 Medicare HMO Blue FlexRx EOC

2021 Medicare HMO Blue PlusRx EOC

2021 Medicare PPO Blue SaverRx EOC

2021 Medicare PPO Blue ValueRx EOC

2021 Medicare PPO Blue PlusRx EOC

Annual Notice of Changes (ANOC)

2021 Medicare HMO Blue SaverRx ANOC - All Counties

2021 Medicare HMO Blue ValueRx ANOC – Worcester County

2021 Medicare HMO Blue Value Rx ANOC – Non-Worcester Counties

2021 Medicare HMO Blue FlexRx ANOC – Worcester County

2021 Medicare HMO Blue FlexRx ANOC – Non-Worcester Counties

2021 Medicare HMO Blue PlusRx ANOC - All Counties

2021 Medicare PPO Blue SaverRx ANOC - All Counties

2021 Medicare PPO ValueRx ANOC – Worcester County

2021 Medicare PPO Blue ValueRx ANOC – Non-Worcester Counties

2021 Medicare PPO Blue PlusRx ANOC - All Counties

Medicare Advantage

2021 LIS Premium Summary Chart

2021 Medicare HMO Blue Star Rating

2021 Medicare PPO Blue Star Rating

Medicare Advantage Subscriber Claim Form

Appointment of a Representative Form (CMS Version)

Enrollment Applications

2021 Medex Enrollment Form

2021 Medicare HMO Blue Enrollment Form

2021 Medicare PPO Blue Enrollment Form

2021 Blue MedicareRx Enrollment Form

2021 Dental Blue 65 Enrollment Form

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.

2021 Medicare Advantage Prescription Claim Form

Express Scripts Home Delivery Form 

2021 List of Medicare Advantage Network Pharmacies

2021 Medicare HMO/PPO Blue 5-Tier Formulary
(Updated 02/01/2021)

2021 Medicare HMO/PPO Blue 6-Tier Formulary
(Updated 02/01/2021​​​​​​​​​​​​​​)

2021 Medicare Advantage Group Formulary
(Updated 02/01/2021​​​​​​​​​​​​​​)

2021 Request for Medicare Prescription Drug Coverage Determination 

Prior Authorization Request Form

2021 Medicare Advantage Prior Authorization Criteria
(Updated 02/01/2021​​​​​​​​​​​​​​​​​​​​​)

2021 Medicare Advantage Step Therapy Criteria 
(Updated 02/01/2021​​​​​​​​​​​​​​​​​​​​​)

2021 Request for Redetermination of Medicare Prescription Drug Denial 

2021 Medicare Advantage Vaccine Claim Form

Fitness and Weight Loss Forms

2021 Medex Fitness Benefit Form

2021 Medex Weight Loss Benefit Form

2021 Medicare Advantage Fitness Benefit Form

2021 Medicare Advantage Weight Loss Benefit Form

Medex

Medex Subscriber Claim Form

Medex Payment Options

Privacy, Nondiscrimination, and Translation Resources

Commitment to Confidentiality

Nondiscrimination Disclosure

Language Translation Services

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

Blue Cross Blue Shield of Massachusetts is an HMO and PPO Plan with a Medicare contract. Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal. Anthem Insurance Companies, Inc., Blue Cross and Blue Shield of Massachusetts, Inc., Blue Cross & Blue Shield of Rhode Island, and Blue Cross and Blue Shield of Vermont are the legal entities that have contracted as a joint enterprise with the Centers for Medicare & Medicaid Services (CMS) and are the risk-bearing entities for Blue MedicareRx (PDP) plans. The joint enterprise is a Medicare-approved Part D Sponsor. Enrollment in Blue MedicareRx (PDP) depends on contract renewal.

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Last Updated: 02/01/2021

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