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    1-888-995-2583 (TTY: 711)

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    1-888-995-2583 (TTY: 711)

    8 a.m. to 8 p.m. 
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    10/1 – 3/31, 7 days a week

    Talk to a Nurse

    1-888-247-2583

    Available 24/7

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    1-888-995-2583 (TTY: 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

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    1-888-995-2583 (TTY: 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

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    1-888-995-2583 (TTY: 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

  • Contact Us

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    1-888-995-2583 (TTY: 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

  • Home
  • Online Forms & Documents
  • 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

      • Legal Representative Form
      • Medex®´ Member Designation of an Authorized Representative
      • Medicare Advantage Billing Change Request
      • Medicare Advantage Designation of an Authorized Representative
      • Prior Drug Coverage Attestation

      Plan Documents

        Designation of Representative

        Medicare Advantage Designation of an Authorized Representative Online Form or View PDF

        Medex®´ Member Designation of an Authorized Representative Online Form or View PDF

        Summary of Benefits/Outlines of Coverage

        2025 Medex®´ Outline of Coverage Updated 10/01/2024

        2025 Medex®´ Freedom of Choice Brochure Updated 10/01/2024

        2025 Medicare HMO Blue Summary of Benefits Updated 10/01/2024

        2025 Medicare PPO Blue Summary of Benefits Updated 10/01/2024

        2025 Blue MedicareRx Summary of Benefits Updated 10/01/2024

        2025 Blue MedicareRx Sales Brochure Updated 10/01/2024

        2025 Dental Blue®´ 65 Outline of Coverage Updated 10/01/2024

        Evidence of Coverage (EOC)

        2025 Medicare HMO Blue SaverRx EOC Updated 10/01/2024

        2025 Medicare HMO Blue ValueRx EOC Updated 10/01/2024

        2025 Medicare HMO Blue FlexRx EOC Updated 10/01/2024

        2025 Medicare HMO Blue PlusRx EOC Updated 10/01/2024

        2025 Medicare PPO Blue SaverRx EOC Updated 10/01/2024

        2025 Medicare PPO Blue ValueRx EOC Updated 10/01/2024

        2025 Medicare PPO Blue PlusRx EOC Updated 10/01/2024

        Annual Notice of Changes (ANOC)

        2025 Medicare HMO Blue SaverRx ANOC - All Counties Updated 10/01/2024

        2025 Medicare HMO Blue ValueRx ANOC – Worcester County Updated 10/01/2024

        2025 Medicare HMO Blue Value Rx ANOC – Non-Worcester Counties Updated 10/01/2024

        2025 Medicare HMO Blue FlexRx ANOC – Worcester County Updated 10/01/2024

        2025 Medicare HMO Blue FlexRx ANOC – Non-Worcester Counties Updated 10/01/2024

        2025 Medicare HMO Blue PlusRx ANOC - All Counties Updated 10/01/2024

        2025 Medicare PPO Blue SaverRx ANOC - All Counties Updated 10/01/2024

        2025 Medicare PPO ValueRx ANOC – Worcester County Updated 10/01/2024

        2025 Medicare PPO Blue ValueRx ANOC – Non-Worcester Counties Updated 10/01/2024

        2025 Medicare PPO Blue PlusRx ANOC - All Counties Updated 10/01/2024

        Enrollment Applications

        2025 Medex®´ Enrollment Form Updated 10/01/2024

        2025 Medicare HMO Blue Enrollment Form Updated 10/01/2024

        2025 Medicare PPO Blue Enrollment Form Updated 10/01/2024

        2025 Blue MedicareRx Enrollment Form Updated 10/01/2024

        2025 Dental Blue®´ 65 Enrollment Form Updated 10/01/2024

        Medicare Advantage

        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.

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          English/English

          ATTENTION: If you speak a language other than English, language assistance services are available to you free of charge. Call 1-800-200-4255 (TTY: 711).

          Spanish/Español

          ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia con el idioma. Llame al número de Servicio al Cliente que figura en su tarjeta de identificación llamada 1-800-472-2689 (TTY: 711).

          Portuguese/Português

          ATENÇÃO: Se fala português, são-lhe disponibilizados gratuitamente serviços de assistência de idiomas. Telefone para os Serviços aos Membros, através do número no seu cartão ID chamar 1-800-472-2689 (TTY: 711).

          French/Français

          ATTENTION : si vous parlez français, des services d’assistance linguistique sont disponibles gratuitement. Appelez le Service adhérents au numéro indiqué sur votre carte d’assuré appel 1-800-472-2689  (TTY : 711).

          Chinese/简体中文

          注意:如果您讲中文,我们可向您免费提供语言协助服务。请拨打您 ID  卡上的号码联系会员服务部 通话 1-800-472-2689(TTY  号码:711)。

          Haitian Creole/Kreyòl Ayisyen

          ATANSYON: Si ou pale kreyòl ayisyen, sèvis asistans nan lang disponib pou ou gratis. Rele nimewo Sèvis Manm nan ki sou kat Idantitifkasyon w lan (Sèvis pou Malantandan Rele 1-800-472-2689 TTY: 711).

          Vietnamese/Tiếng Việt

          LƯU .: Nếu quý vị n.i Tiếng Việt, c.c dịch vụ hỗ trợ ng.n ngữ được cung cấp cho quý vị miễn ph.. Gọi cho Dịch vụ Hội vi.n theo số tr.n thẻ ID của quý vị Cuộc gọi 1-800-472-2689 (TTY: 711).

          Russian/Русский

          ВНИМАНИЕ: если Вы говорите по-русски, Вы можете воспользоваться бесплатными услугами переводчика. Позвоните в отдел обслуживания клиентов по номеру, указанному в Вашей идентификационной карте вызов 1-800-472-2689 (телетайп: 711).

          Mon-Khmer, Cambodian/ខ្មែរ

          ការជូនដំណឹង៖ ប្រសិនប. ើអ្នកនិយាយភាសា ខ្មែរ សេ  វាជំនួយភាសាឥតគិតថ្លៃ គឺអាចរកបានសម្  រាប ់អ្នក។ សូមទូរស័ព្ទទ ៅផ ្នែ កសេ  វាសមា  ជិកតាមល េខន  ៅល.  ើប ័ណ្ណ សម្  គាល ់ខ្លួ ខ្លួ នរប ស់អ្នក ហៅ 1-800-472-2689 (TTY: 711) ។

          Italian/Italiano

          ATTENZIONE: se parlate italiano, sono disponibili per voi servizi gratuiti di assistenza linguistica. Chiamate il Servizio per i membri al numero riportato sulla vostra scheda identificativa chiamata 1-800-472-2689 (TTY: 711).

          Korean/한국어

          참고 : 한국어를 사용하는 경우 언어 지원 서비스를 무료로 사용할 수 있습니다. 신분증에있는 전화 번호 1-800-472-2689 (TTY : 711)로 회원 서비스에 연락하십시오.

          Polish/Polski

          UWAGA: Osoby posługujące się językiem polskim mogą bezpłatnie skorzystać z pomocy językowej. Należy zadzwonić do Działu obsługi ubezpieczonych pod numer podany na identyfikatorze zadzwoń 1-800-472-2689 (TTY: 711).

          Hindi/हिंदी

          ध्यान दें: य दि  आप ह िन् दी बोलते ह ैं, तो भा षा  सहाय  ता  सेवा एँ, आप के लि ए नि :शुल्क  उपलब्ध ह ैं। सदस्य  सेवा ओं को आपके आई.डी. कार  ्ड पर दि ए गए नंबर पर कॉल करें  कॉल 1-800-472-2689 ( टी .टी .वा ई.: 711).

          Gujarati/ગુજરાતી

          ધ્યાન આપો:  જો તમે ગુજરા તી બોલતા  હો, તો તમને ભા ષા કીય  સહાય  તા  સેવા ઓ વિ ના  મૂલ્યે  ઉપલબ્ધ છે. તમા રા  આઈડી કાર  ્ડ પર આપેલા  નંબર પર Member Service  ને કૉલ કરો કૉલ કરો 1-800-472-2689 (TTY: 711).

          Tagalog/Tagalog

          PAUNAWA: Kung nagsasalita ka ng wikang Tagalog, mayroon kang magagamit na mga libreng serbisyo para sa tulong sa wika. Tawagan ang Mga Serbisyo sa Miyembro sa numerong nasa iyong ID Card tumawag 1-800-472-2689 (TTY: 711).

          Japanese/日本語

          お知らせ:日本語をお話しになる方は無料の言語アシスタンスサービスをご利用いただけます。ID カードに記載の電話番号を使用してメンバーサービスまでお電話ください 呼び出す 1-800-472-2689(TTY: 711)。

          German/Deutsch

          ACHTUNG: Wenn Sie Deutsche sprechen, steht Ihnen kostenlos fremdsprachliche Unterstützung zur Verfügung. Rufen Sie den Mitgliederdienst unter der Nummer auf Ihrer ID-Karte an Anrufen 1-800-472-2689 (TTY: 711).

          Lao/ພາສາລາວ

          ຂໍ້ຄວນໃສ່ໃຈ: ຖ້າເຈົ້າເວົ້າພາສາລາວໄດ້, ມີການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາໃຫ້ທ່ານໂດຍບໍ່ເສຍຄ່າ. ໂທ ຫາ ຝ່າຍບໍລິການສະ ມາ ຊິກທີ່ໝາຍເລກໂທລະສັບຢູ່ໃນບັດຂອງທ່ານ ໂທ 1-800-472-2689 (TTY: 711).

          Navajo/Diné Bizaad

          BAA !KOHWIINDZIN DOO&G&: Din4 k’ehj7 y1n7[t’i’go saad bee y1t’i’ 47 t’11j77k’e bee n7k1’a’doowo[go 47 n1’ahoot’i’. D77 bee an7tah7g7 ninaaltsoos bine’d44’ n0omba bik1’7g7ij8’ b44sh bee hod77lnih call 1-800-472-2689 (TTY: 711).

          Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and Blue Shield Association. ® Registered Marks of the Blue Cross and Blue Shield Association. ® , ® , TM, SM Registered, Service, and Trade Marks are the property of their respective owners. © 2024 Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc.

          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_24100_M_2025 | S2893_2432_2025 | Last Updated: 10/01/2024