Find everything you need in our collection of Massachusetts Medicare plan forms and documents.
Summary of Benefits/Outlines of Coverage
2019 Medex®' Outline of Coverage
2019 Medex Choice: Solution to Supplement Medicare Brochure
2019 Medicare HMO Blue Summary of Benefits
2019 Dental Blue 65 Outline of Coverage
2019 Medicare PPO Blue Summary of Benefits
Evidence of Coverage (EOC)
2019 Medicare HMO Blue SaverRx EOC
2019 Medicare HMO Blue ValueRx EOC
2019 Medicare HMO Blue FlexRx EOC
2019 Medicare HMO Blue PlusRx EOC
2019 Medicare PPO Blue SaverRx EOC
2019 Medicare PPO Blue ValueRx EOC
2019 Medicare PPO Blue PlusRx EOC
Annual Notice of Changes (ANOC)
2019 Medicare HMO Blue ValueRx ANOC – Worcester County
2019 Medicare HMO Blue Value Rx ANOC – Non-Worcester Counties
2019 Medicare HMO Blue FlexRx ANOC – Worcester County
2019 Medicare HMO Blue FlexRx ANOC – Non-Worcester Counties
2019 Medicare HMO Blue PlusRx ANOC - All Counties
2019 Medicare PPO Blue SaverRx ANOC - All Counties
2019 Medicare PPO ValueRx ANOC – Worcester County
2019 Medicare PPO Blue ValueRx ANOC – Non-Worcester Counties
2019 Medicare PPO Blue PlusRx ANOC - All Counties
Enrollment Applications
2019 Medex Bronze and Medex Core Application
2019 Medicare HMO Blue Enrollment Form
2019 Medicare PPO Blue Enrollment Form
2019 Dental Blue 65 Preventive/Basic/Premier Application
2019 Blue MedicareRx Application
Medicare Advantage
2019 LIS Premium Summary Chart
2019 Medicare HMO Blue Star Rating
2019 Medicare PPO Blue Star Rating
Medicare Advantage Member's Designation of a Personal Representative Form
Value-Based Insurance Design (VBID) Drug List
Medicare Advantage Subscriber Claim Form
Medicare Advantage Appointment of a Representative 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.
2019 Medicare Advantage Prescription Claim Form
Express Scripts Home Delivery Form
2019 List of Medicare Advantage Network Pharmacies
2019 Medicare HMO Blue Formulary
Updated 10/1/2018
2019 Medicare PPO Blue Formulary
Updated 10/1/2018
2019 Medicare Advantage Group Formulary
Updated 10/1/2018
2019 Request for Medicare Prescription Drug Coverage Determination
Prior Authorization Request Form
2019 Medicare Advantage Prior Authorization Criteria
(Updated 10/15/2018)
2019 Medicare Advantage Step Therapy Criteria
Updated 10/1/2018
2019 Request for Redetermination of Medicare Prescription Drug Denial
2019 Medicare Advantage Vaccine Claim Form
Fitness and Weight Loss Forms
2019 Medex Fitness Benefit Form
2019 Medex Weight Loss Benefit Form
2019 Medicare Advantage Fitness Benefit Form
2019 Medicare Advantage Weight Loss Benefit Form
Medex
Medex Choice Referral Fact Sheet