Skip to main content
  • Blue Cross Blue Shield of Massachusetts Logo Blue Cross Blue Shield of Massachusetts Logo
  • Menu
    • Medicare Options
    • Home
    • Find a Doctor
    • My Account
      • Pay My Bill with Direct-Pay
      • MyBlue
    • Shop Plans
      • 2023 Plans
        • 2023 Medicare Advantage Plans
          • Medicare PPO Blue SaverRx
          • Medicare PPO Blue ValueRx
          • Medicare PPO Blue PlusRx
          • Medicare HMO Blue SaverRx
          • Medicare HMO Blue ValueRx
          • Medicare HMO Blue FlexRx
          • Medicare HMO Blue PlusRx
        • 2023 Medicare Supplement Plans
          • Medex Core
          • Medex Sapphire
          • Medex Bronze
          • Medex Vision & Hearing
        • 2023 Prescription Drug Plans
        • 2023 Dental Plans
        • 2023 Group Plans
        • 2023 Travel Medical Insurance Plans
    • Learn More
      • Intro to Medicare
        • Introduction
        • Eligibility and Enrollment
        • Frequently Asked Questions
        • Your Coverage Choices
        • Original Medicare
        • Medicare Advantage
        • Prescription Drug Coverage
        • Plan that’s Right for you
        • Sign-Up for a Guide Book and Email
        • Medicare Basics Video Series
      • Are You Eligible For Medicare?
      • Are Your Drugs Covered?
      • Attend a Seminar
      • About Medicare
        • Health Plan Basics
        • Important Dates
      • Request a Call
    • Health & Wellness
      • Finding Care
        • 24-Hour Nurse Line
        • Care Management
        • ER Alternatives
        • Find a Doctor
        • Member Support & Assistance Program
          • In-home Care from Landmark Health
          • In-home Health Assessments with Signify Health®´
          • Personalized Support for Disease Management
          • Quality Optimizer
          • Additional Programs
        • Mental Health
        • Supporting Caregivers
      • Manage Your Health
        • Managing Diabetes
        • Preventive Care
        • Flu Prevention
        • Chronic Care
        • Fall Prevention
        • Urinary Incontinence
        • Meals and Nutrition
    • Member Resources
      • Plan Information
        • Plan Documents
        • Quality Assurance
        • National Coverage Determination
        • Ending Membership
      • Pharmacy Benefits
        • Drug Benefits
          • Home Delivery
          • Formulary Overview
          • Coverage Requirements
          • Formulary Changes
        • Medicare Advantage Pharmacy Network
        • Plan Drug Transition Policy
        • Medication Therapy Management
        • Prescription Drug Utilization Review
      • Learn to Live
      • Get More With MyBlue
      • Discounts & Programs
      • Payment Options
      • Fraud & Disaster
      • Appeals & Grievances
        • Medicare Advantage Part C Medical Care Plan Rights
        • Medicare Advantage Part D Prescription Drug Plan Rights
      • Medicare Advantage Billing Change Request
      • Medicare Advantage Designation of an Authorized Representative
      • Medex Member Designation of an Authorized Representative
      • Prior Prescription Drug Coverage
      • Contact Us
    • Other Sites
      • Blue Cross MA Home
      • MyBlue
      • Employer
      • Broker
      • Careers
      • About Us
      • Contact Support
  • {Mobile Break}
  • Medicare Options
  • Search
  • Get Care
    • Contact Us
    • Request a Call

     Call Medicare Sales

    1-800-678-2265TTY 711

    8 a.m. to 8 p.m.
    4/1 - 9/30, Mon. – Fri.
    10/1 – 3/31, 7 days a week

     Talk to a Nurse

    1-888-247-2583

    Available 24/7

  • Account

    Sign-in to MyBlue

  • Menu
    • Medicare Options
    • Home
    • Find a Doctor
    • My Account
      • Pay My Bill with Direct-Pay
      • MyBlue
    • Shop Plans
      • 2023 Plans
        • 2023 Medicare Advantage Plans
          • Medicare PPO Blue SaverRx
          • Medicare PPO Blue ValueRx
          • Medicare PPO Blue PlusRx
          • Medicare HMO Blue SaverRx
          • Medicare HMO Blue ValueRx
          • Medicare HMO Blue FlexRx
          • Medicare HMO Blue PlusRx
        • 2023 Medicare Supplement Plans
          • Medex Core
          • Medex Sapphire
          • Medex Bronze
          • Medex Vision & Hearing
        • 2023 Prescription Drug Plans
        • 2023 Dental Plans
        • 2023 Group Plans
        • 2023 Travel Medical Insurance Plans
    • Learn More
      • Intro to Medicare
        • Introduction
        • Eligibility and Enrollment
        • Frequently Asked Questions
        • Your Coverage Choices
        • Original Medicare
        • Medicare Advantage
        • Prescription Drug Coverage
        • Plan that’s Right for you
        • Sign-Up for a Guide Book and Email
        • Medicare Basics Video Series
      • Are You Eligible For Medicare?
      • Are Your Drugs Covered?
      • Attend a Seminar
      • About Medicare
        • Health Plan Basics
        • Important Dates
      • Request a Call
    • Health & Wellness
      • Finding Care
        • 24-Hour Nurse Line
        • Care Management
        • ER Alternatives
        • Find a Doctor
        • Member Support & Assistance Program
          • In-home Care from Landmark Health
          • In-home Health Assessments with Signify Health®´
          • Personalized Support for Disease Management
          • Quality Optimizer
          • Additional Programs
        • Mental Health
        • Supporting Caregivers
      • Manage Your Health
        • Managing Diabetes
        • Preventive Care
        • Flu Prevention
        • Chronic Care
        • Fall Prevention
        • Urinary Incontinence
        • Meals and Nutrition
    • Member Resources
      • Plan Information
        • Plan Documents
        • Quality Assurance
        • National Coverage Determination
        • Ending Membership
      • Pharmacy Benefits
        • Drug Benefits
          • Home Delivery
          • Formulary Overview
          • Coverage Requirements
          • Formulary Changes
        • Medicare Advantage Pharmacy Network
        • Plan Drug Transition Policy
        • Medication Therapy Management
        • Prescription Drug Utilization Review
      • Learn to Live
      • Get More With MyBlue
      • Discounts & Programs
      • Payment Options
      • Fraud & Disaster
      • Appeals & Grievances
        • Medicare Advantage Part C Medical Care Plan Rights
        • Medicare Advantage Part D Prescription Drug Plan Rights
      • Medicare Advantage Billing Change Request
      • Medicare Advantage Designation of an Authorized Representative
      • Medex Member Designation of an Authorized Representative
      • Prior Prescription Drug Coverage
      • Contact Us
    • Other Sites
      • Blue Cross MA Home
      • MyBlue
      • Employer
      • Broker
      • Careers
      • About Us
      • Contact Support

 1-800-678-2265      TTY: 711

8:00 a.m. to 8:00 p.m. ET, Seven Days a Week.

  • Shop Plans
    • 2023 Plans
      • 2023 Medicare Advantage Plans
        • Medicare PPO Blue SaverRx
        • Medicare PPO Blue ValueRx
        • Medicare PPO Blue PlusRx
        • Medicare HMO Blue SaverRx
        • Medicare HMO Blue ValueRx
        • Medicare HMO Blue FlexRx
        • Medicare HMO Blue PlusRx
      • 2023 Medicare Supplement Plans
        • Medex Core
        • Medex Sapphire
        • Medex Bronze
        • Medex Vision & Hearing
      • 2023 Prescription Drug Plans
      • 2023 Dental Plans
      • 2023 Group Plans
      • 2023 Travel Medical Insurance Plans
  • Learn More
    • Intro to Medicare
      • Introduction
      • Eligibility and Enrollment
      • Frequently Asked Questions
      • Your Coverage Choices
      • Original Medicare
      • Medicare Advantage
      • Prescription Drug Coverage
      • Plan that’s Right for you
      • Sign-Up for a Guide Book and Email
      • Medicare Basics Video Series
    • Are You Eligible For Medicare?
    • Are Your Drugs Covered?
    • Attend a Seminar
    • About Medicare
      • Health Plan Basics
      • Important Dates
    • Request a Call
  • Health & Wellness
    • Finding Care
      • 24-Hour Nurse Line
      • Care Management
      • ER Alternatives
      • Find a Doctor
      • Member Support & Assistance Program
        • In-home Care from Landmark Health
        • In-home Health Assessments with Signify Health®´
        • Personalized Support for Disease Management
        • Quality Optimizer
        • Additional Programs
      • Mental Health
      • Supporting Caregivers
    • Manage Your Health
      • Managing Diabetes
      • Preventive Care
      • Flu Prevention
      • Chronic Care
      • Fall Prevention
      • Urinary Incontinence
      • Meals and Nutrition
  • Member Resources
    • Plan Information
      • Plan Documents
      • Quality Assurance
      • National Coverage Determination
      • Ending Membership
    • Pharmacy Benefits
      • Drug Benefits
        • Home Delivery
        • Formulary Overview
        • Coverage Requirements
        • Formulary Changes
      • Medicare Advantage Pharmacy Network
      • Plan Drug Transition Policy
      • Medication Therapy Management
      • Prescription Drug Utilization Review
    • Learn to Live
    • Get More With MyBlue
    • Discounts & Programs
    • Payment Options
    • Fraud & Disaster
    • Appeals & Grievances
      • Medicare Advantage Part C Medical Care Plan Rights
      • Medicare Advantage Part D Prescription Drug Plan Rights
    • Medicare Advantage Billing Change Request
    • Medicare Advantage Designation of an Authorized Representative
    • Medex Member Designation of an Authorized Representative
    • Prior Prescription Drug Coverage
    • Contact Us
  • Other Sites
    • Blue Cross MA Home
    • MyBlue
    • Employer
    • Broker
    • Careers
    • About Us
    • Contact Support

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 or Submit Online

Medex Member Designation of an Authorized Representative or Submit Online

Summary of Benefits/Outlines of Coverage

2023 Medex®' Outline of Coverage

2023 Medex Freedom of Choice Brochure

2023 Medicare HMO Blue Summary of Benefits Updated 10/01/2022

2023 Medicare PPO Blue Summary of Benefits Updated 10/01/2022

2023 Blue MedicareRx Summary of Benefits Updated 10/01/2022

2023 Blue MedicareRx Sales Brochure

2023 Dental Blue 65 Outline of Coverage

Evidence of Coverage (EOC)

2023 Medicare HMO Blue SaverRx EOC Updated 10/01/2022

2023 Medicare HMO Blue ValueRx EOC Updated 10/01/2022

2023 Medicare HMO Blue FlexRx EOC Updated 10/01/2022

2023 Medicare HMO Blue PlusRx EOC Updated 10/01/2022

2023 Medicare PPO Blue SaverRx EOC Updated 10/01/2022

2023 Medicare PPO Blue ValueRx EOC Updated 10/01/2022

2023 Medicare PPO Blue PlusRx EOC Updated 10/01/2022

Part B IRA Change Notice Updated 03/01/2023

Annual Notice of Changes (ANOC)

2023 Medicare HMO Blue SaverRx ANOC - All Counties Updated 10/01/2022

2023 Medicare HMO Blue ValueRx ANOC – Worcester County Updated 10/01/2022

2023 Medicare HMO Blue Value Rx ANOC – Non-Worcester Counties Updated 10/01/2022

2023 Medicare HMO Blue FlexRx ANOC – Worcester County Updated 10/01/2022

2023 Medicare HMO Blue FlexRx ANOC – Non-Worcester Counties Updated 10/01/2022

2023 Medicare HMO Blue PlusRx ANOC - All Counties Updated 10/01/2022

2023 Medicare PPO Blue SaverRx ANOC - All Counties Updated 10/01/2022

2023 Medicare PPO ValueRx ANOC – Worcester County Updated 10/01/2022

2023 Medicare PPO Blue ValueRx ANOC – Non-Worcester Counties Updated 10/01/2022

2023 Medicare PPO Blue PlusRx ANOC - All Counties Updated 10/01/2022

Part B IRA Change Notice Updated 03/01/2023

Enrollment Applications

2023 Medex Enrollment Form

2023 Medicare HMO Blue Enrollment Form

2023 Medicare PPO Blue Enrollment Form

2023 Blue MedicareRx Enrollment Form

2023 Dental Blue 65 Enrollment Form

Medicare Advantage

2023 LIS Premium Summary Chart

2023 Medicare HMO Blue Star Rating Updated 10/29/2022

2023 Medicare PPO Blue Star Rating Updated 10/29/2022

Medicare Advantage Subscriber Claim Form

Appointment of a Representative Form (CMS Version)

Medicare Advantage Payment Options

Pre-certification / Pre-Authorization Request Form Updated 10/01/2022

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

Mail Service Pharmacy Form

2023 List of Medicare Advantage Network Pharmacies

2023 Medicare HMO Blue Formulary
Updated 03/16/2023

2023 Medicare PPO Blue Formulary
Updated 03/16/2023

2023 Medicare Advantage Group 3-Tier Formulary
Updated 03/16/2023

2023 Medicare Advantage Group 2-Tier Formulary
Updated 03/16/2023

Request for Medicare Prescription Drug Coverage Determination

Prior Authorization Request Form

2023 Medicare Advantage Prior Authorization Criteria
Updated on 03/16/2023

2023 Medicare Advantage Step Therapy Criteria
Updated on 10/01/2022

Request for Redetermination of Medicare Prescription Drug Denial 

Medicare Advantage Vaccine Claim Form

Reimbursement Forms

2023 Medex Fitness Benefit Form

2023 Medex Weight Loss Benefit Form

2023 Medicare Advantage Fitness Benefit Form

2023 Medicare Advantage Weight Loss Benefit Form

2023 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

Designation of Representative

Medicare Advantage Member's Designation of a Personal Representative Form or Submit Online

Medex Member Designation of an Authorized Representative or Submit Online

Summary of Benefits/Outlines of Coverage

2023 Medex®' Outline of Coverage

2023 Medex Freedom of Choice Brochure

2023 Medicare HMO Blue Summary of Benefits Updated 10/01/2022

2023 Medicare PPO Blue Summary of Benefits Updated 10/01/2022

2023 Blue MedicareRx Summary of Benefits Updated 10/01/2022

2023 Blue MedicareRx Sales Brochure

2023 Dental Blue 65 Outline of Coverage

 

 

Evidence of Coverage (EOC)

2023 Medicare HMO Blue SaverRx EOC Updated 10/01/2022

2023 Medicare HMO Blue ValueRx EOC Updated 10/01/2022

2023 Medicare HMO Blue FlexRx EOC Updated 10/01/2022

2023 Medicare HMO Blue PlusRx EOC Updated 10/01/2022

2023 Medicare PPO Blue SaverRx EOC Updated 10/01/2022

2023 Medicare PPO Blue ValueRx EOC Updated 10/01/2022

2023 Medicare PPO Blue PlusRx EOC Updated 10/01/2022

Part B IRA Change Notice Updated 03/01/2023

 

Annual Notice of Changes (ANOC)

2023 Medicare HMO Blue SaverRx ANOC - All Counties Updated 10/01/2022

2023 Medicare HMO Blue ValueRx ANOC – Worcester County Updated 10/01/2022

2023 Medicare HMO Blue Value Rx ANOC – Non-Worcester Counties Updated 10/01/2022

2023 Medicare HMO Blue FlexRx ANOC – Worcester County Updated 10/01/2022

2023 Medicare HMO Blue FlexRx ANOC – Non-Worcester Counties Updated 10/01/2022

2023 Medicare HMO Blue PlusRx ANOC - All Counties Updated 10/01/2022

2023 Medicare PPO Blue SaverRx ANOC - All Counties Updated 10/01/2022

2023 Medicare PPO ValueRx ANOC – Worcester County Updated 10/01/2022

2023 Medicare PPO Blue ValueRx ANOC – Non-Worcester Counties Updated 10/01/2022

2023 Medicare PPO Blue PlusRx ANOC - All Counties Updated 10/01/2022

Part B IRA Change Notice Updated 03/01/2023

Enrollment Applications

2023 Medex Enrollment Form

2023 Medicare HMO Blue Enrollment Form

2023 Medicare PPO Blue Enrollment Form

2023 Blue MedicareRx Enrollment Form

2023 Dental Blue 65 Enrollment Form

 

Medicare Advantage

2023 LIS Premium Summary Chart

2023 Medicare HMO Blue Star Rating Updated 10/29/2022

2023 Medicare PPO Blue Star Rating Updated 10/29/2022

Medicare Advantage Subscriber Claim Form

Appointment of a Representative Form (CMS Version)

Medicare Advantage Payment Options

Pre-certification / Pre-Authorization Request Form Updated 10/01/2022

 

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

Mail Service Pharmacy Form

2023 List of Medicare Advantage Network Pharmacies

2023 Medicare HMO Blue Formulary
Updated 03/16/2023

2023 Medicare PPO Blue Formulary
Updated 03/16/2023

2023 Medicare Advantage Group 3-Tier Formulary
Updated 03/16/2023

2023 Medicare Advantage Group 2-Tier Formulary
Updated 03/16/2023

Request for Medicare Prescription Drug Coverage Determination

Prior Authorization Request Form

2023 Medicare Advantage Prior Authorization Criteria
Updated on 03/16/2023

2023 Medicare Advantage Step Therapy Criteria
Updated on 10/01/2022

Request for Redetermination of Medicare Prescription Drug Denial 

Medicare Advantage Vaccine Claim Form

 

Reimbursement Forms

2023 Medex Fitness Benefit Form

2023 Medex Weight Loss Benefit Form

2023 Medicare Advantage Fitness Benefit Form

2023 Medicare Advantage Weight Loss Benefit Form

2023 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

 

To request 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.

Designation of Representative

Medicare Advantage Member's Designation of a Personal Representative Form or Submit Online

Medex Member Designation of an Authorized Representative or Submit Online

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 10/01/2022

2022 Medicare PPO Blue Summary of Benefits Updated 10/01/2022

2022 Blue MedicareRx Summary of Benefits Updated 10/01/2022

2022 Blue MedicareRx Sales Brochure

2022 Dental Blue 65 Outline of Coverage

Evidence of Coverage (EOC)

2022 Medicare HMO Blue SaverRx EOC Updated 10/01/2022

2022 Medicare HMO Blue ValueRx EOC Updated 10/01/2022

2022 Medicare HMO Blue FlexRx EOC Updated 10/01/2022

2022 Medicare HMO Blue PlusRx EOC Updated 10/01/2022

2022 Medicare PPO Blue SaverRx EOC Updated 10/01/2022

2022 Medicare PPO Blue ValueRx EOC Updated 10/01/2022

2022 Medicare PPO Blue PlusRx EOC Updated 10/01/2022

Annual Notice of Changes (ANOC)

2022 Medicare HMO Blue SaverRx ANOC - All Counties Updated 10/01/2022

2022 Medicare HMO Blue ValueRx ANOC – Worcester County Updated 10/01/2022

2022 Medicare HMO Blue Value Rx ANOC – Non-Worcester Counties Updated 10/01/2022

2022 Medicare HMO Blue FlexRx ANOC – Worcester County Updated 10/01/2022

2022 Medicare HMO Blue FlexRx ANOC – Non-Worcester Counties Updated 10/01/2022

2022 Medicare HMO Blue PlusRx ANOC - All Counties Updated 10/01/2022

2022 Medicare PPO Blue SaverRx ANOC - All Counties Updated 10/01/2022

2022 Medicare PPO ValueRx ANOC – Worcester County Updated 10/01/2022

2022 Medicare PPO Blue ValueRx ANOC – Non-Worcester Counties Updated 10/01/2022

2022 Medicare PPO Blue PlusRx ANOC - All Counties Updated 10/01/2022

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 10/01/2022

2022 Medicare PPO Blue Star Rating Updated 10/01/2022

Medicare Advantage Subscriber Claim Form

Appointment of a Representative Form (CMS Version)

Medicare Advantage Payment Options

Pre-certification / Pre-Authorization Request Form Updated 10/01/2022

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 11/01/2022

2022 Medicare PPO Blue Formulary
Updated 11/01/2022

2022 Medicare Advantage Group 3-Tier Formulary
Updated 11/01/2022

2022 Medicare Advantage Group 2-Tier Formulary
Updated 11/01/2022

Request for Medicare Prescription Drug Coverage Determination

Prior Authorization Request Form

2022 Medicare Advantage Prior Authorization Criteria
Updated 11/01/2022

2022 Medicare Advantage Step Therapy Criteria
Updated 11/01/2022

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

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 10/01/2022

2022 Medicare PPO Blue Summary of Benefits Updated 10/01/2022

2022 Blue MedicareRx Summary of Benefits Updated 10/01/2022

2022 Blue MedicareRx Sales Brochure

2022 Dental Blue 65 Outline of Coverage

 

Evidence of Coverage (EOC)

2022 Medicare HMO Blue SaverRx EOC Updated 10/01/2022

2022 Medicare HMO Blue ValueRx EOC Updated 10/01/2022

2022 Medicare HMO Blue FlexRx EOC Updated 10/01/2022

2022 Medicare HMO Blue PlusRx EOC Updated 10/01/2022

2022 Medicare PPO Blue SaverRx EOC Updated 10/01/2022

2022 Medicare PPO Blue ValueRx EOC Updated 10/01/2022

2022 Medicare PPO Blue PlusRx EOC Updated 10/01/2022

 

Annual Notice of Changes (ANOC)

 

2022 Medicare HMO Blue SaverRx ANOC - All Counties Updated 10/01/2022

2022 Medicare HMO Blue ValueRx ANOC – Worcester County Updated 10/01/2022

2022 Medicare HMO Blue Value Rx ANOC – Non-Worcester Counties Updated 10/01/2022

2022 Medicare HMO Blue FlexRx ANOC – Worcester County Updated 10/01/2022

2022 Medicare HMO Blue FlexRx ANOC – Non-Worcester Counties Updated 10/01/2022

2022 Medicare HMO Blue PlusRx ANOC - All Counties Updated 10/01/2022

2022 Medicare PPO Blue SaverRx ANOC - All Counties Updated 10/01/2022

2022 Medicare PPO ValueRx ANOC – Worcester County Updated 10/01/2022

2022 Medicare PPO Blue ValueRx ANOC – Non-Worcester Counties Updated 10/01/2022

2022 Medicare PPO Blue PlusRx ANOC - All Counties Updated 10/01/2022

 

 

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 10/01/2022

2022 Medicare PPO Blue Formulary
Updated 10/01/2022

2022 Medicare Advantage Group 3-Tier Formulary
Updated 10/01/2022

2022 Medicare Advantage Group 2-Tier Formulary
Updated 10/01/2022

Request for Medicare Prescription Drug Coverage Determination

Prior Authorization Request Form

2022 Medicare Advantage Prior Authorization Criteria
Updated 10/01/2022

2022 Medicare Advantage Step Therapy Criteria
Updated 10/01/2022

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

To request 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.

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.

You can file a complaint if you feel that you received inaccurate, misleading or inappropriate information. Please call Member Service at 1-800-200-4255 (TTY users call: 711). If your complaint involves a broker or agent, be sure to include the name of the broker/agent when filing your complaint.

Y0014_22146
S2893_2244
Last Updated: 03/16/2023

Social Media Links

  • Facebook
  • Twitter
  • Linkedin
  • Youtube
  • itunes app
  • google play app

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ®, ℠ Registered and Service Marks of the Blue Cross and Blue Shield Association. ®' Registered Marks of Blue Cross Blue Shield of Massachusetts. ®’’, ℠´, ™ Registered Service and Trade Marks are property of their respective owners. ©   Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

Footer Menu

  • About Us
  • Terms of Use, Privacy & Security
  • Accessibility
  • Sitemap
  • Nondiscrimination and Translations Resources