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
2020 Medex®' Outline of Coverage
2020 Medex Freedom of Choice Brochure
2020 Medicare HMO Blue Summary of Benefits
2020 Medicare PPO Blue Summary of Benefits
2020 Blue MedicareRx Summary of Benefits
2020 Blue MedicareRx Sales Brochure
2020 Dental Blue 65 Outline of Coverage
Evidence of Coverage (EOC)
2020 Medicare HMO Blue SaverRx EOC
2020 Medicare HMO Blue ValueRx EOC
2020 Medicare HMO Blue FlexRx EOC
2020 Medicare HMO Blue PlusRx EOC
2020 Medicare PPO Blue SaverRx EOC
2020 Medicare PPO Blue ValueRx EOC
2020 Medicare PPO Blue PlusRx EOC
Annual Notice of Changes (ANOC)
2020 Medicare HMO Blue SaverRx ANOC - All Counties
2020 Medicare HMO Blue ValueRx ANOC – Worcester County
2020 Medicare HMO Blue Value Rx ANOC – Non-Worcester Counties
2020 Medicare HMO Blue FlexRx ANOC – Worcester County
2020 Medicare HMO Blue FlexRx ANOC – Non-Worcester Counties
2020 Medicare HMO Blue PlusRx ANOC - All Counties
2020 Medicare PPO Blue SaverRx ANOC - All Counties
2020 Medicare PPO ValueRx ANOC – Worcester County
2020 Medicare PPO Blue ValueRx ANOC – Non-Worcester Counties
2020 Medicare PPO Blue PlusRx ANOC - All Counties
Enrollment Applications
2020 Medex Enrollment Form
2020 Medicare HMO Blue Enrollment Form
2020 Medicare PPO Blue Enrollment Form
2020 Blue MedicareRx Enrollment Form
2020 Dental Blue 65 Enrollment Form
Medicare Advantage
2020 LIS Premium Summary Chart
2020 Medicare HMO Blue Star Rating
2020 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 [email protected].
2020 Medicare Advantage Prescription Claim Form
Express Scripts Home Delivery Form
2020 List of Medicare Advantage Network Pharmacies
2020 Medicare HMO Blue Formulary
Updated 4/1/2020
2020 Medicare PPO Blue Formulary
Updated 4/1/2020
2020 Medicare Advantage Group Formulary
Updated 4/1/2020
2020 Request for Medicare Prescription Drug Coverage Determination
Prior Authorization Request Form
2020 Medicare Advantage Prior Authorization Criteria
Updated 4/1/2020
2020 Medicare Advantage Step Therapy Criteria
Updated 4/1/2020
2020 Request for Redetermination of Medicare Prescription Drug Denial
2020 Medicare Advantage Vaccine Claim Form
Fitness and Weight Loss Forms
2020 Medex Fitness Benefit Form
2020 Medex Weight Loss Benefit Form
2020 Medicare Advantage Fitness Benefit Form
2020 Medicare Advantage Weight Loss Benefit Form
Medex
Medex Choice Referral Fact Sheet
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