Online Forms & Plan Documents

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

Online Forms

Online forms that members can submit

Plan Documents

2025 Medicare Advantage Flex Card Purchase & Fitness/Weight Loss Reimbursement Form Effective 10/01/2024
Note: To be used when using your Flex Card isn’t possible. Amazon, Facebook Marketplace, and Ebay purchases are not reimbursable expenses under the Flex Card.

2025 In-Home Support Directory Updated 10/01/2024

2025 Medicare Advantage Part B Step Therapy Program Drug List Effective 10/01/2024

2025 LIS Premium Summary Chart Updated 10/01/2024

2025 Medicare HMO Blue Star Rating Updated 10/10/2024

2025 Medicare PPO Blue Star Rating Updated 10/10/2024

2025 Over-the-Counter Catalog Updated 10/01/2024

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.

2025 List of Medicare Advantage Network Pharmacies Updated on 10/01/2024

2025 Medicare HMO Blue Formulary Updated on 05/01/2025

2025 Medicare PPO Blue Formulary Updated on 05/01/2025

2025 Medicare Advantage Group 3-Tier Formulary Updated on 05/01/2025

2025 Medicare Advantage Group 2-Tier Formulary Updated on 05/01/2025

2025 Medicare Advantage Prior Authorization Criteria Updated on 05/01/2025

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 12/01/2024

Medicare Advantage Vaccine Claim Form Updated on 10/01/2023

EyeMed

EyeMed^®´´ Claims Form Updated on 10/01/2023

Medex

2025 Medex^®´ Fitness Benefit Form Updated on 10/01/2024

2025 Medex^®´Weight Loss Benefit Form Updated on 10/01/2024

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

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.

Healthy Times for Medicare Advantage members

Healthy Times for Medex members

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.