Medicare Advantage Plan Documents
Find the documents you need to manage your Medicare Advantage Prescription Drug plan offered by Blue Cross and Blue Shield of Texas.
View these forms and documents in Spanish. If you have questions, please Contact Us.
Abilene and Sweetwater Areas
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
Amarillo Area
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Value (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Value (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
Austin Area
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 11/17/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Choice Premier (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- H4801003
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H4801003
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H4801003
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Value (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex Access (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Value (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
Beaumont and Port Arthur Areas
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Choice Premier (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- H4801002
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801010
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H4801002
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801010
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H4801002
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex Access (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
Corpus Christi Area
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- H4801004
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801006
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H4801004
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801006
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H4801004
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Value (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Value (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
Dallas and Ft Worth Areas
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Choice Premier (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- H4801001
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801009
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801012
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H4801001
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801009
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801012
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H4801001
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Value (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex Access (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver Plus (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Value (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
El Paso (Las Cruces) Area
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Value (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
Houston Area
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Choice Premier (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- H4801002
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801004
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801010
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801012
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H4801002
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801004
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801010
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801012
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H4801002
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Value (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex Access (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Value (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
Laredo Area
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
North East Texas Area
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Value (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Value (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
North Texas Area
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- H4801001
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801012
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H4801001
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801012
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H4801001
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Value (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Value (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
San Angelo Area
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- H4801011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801017
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H4801011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801017
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H4801011
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Value (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Value (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
San Antonio Area
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- H4801004
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801006
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H4801004
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801006
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H4801004
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Value (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex Access (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Value (HMO)SM
General Plan Information- H8554001
- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
- H9706009
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- H8554001
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Pharmacy Directory – Last Updated 03/01/2023
- H9706009
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Pharmacy Directory – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H8554001
- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
- H9706009
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Not yet available
Prescription Drug Information
- H8554001
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Pharmacy Directory – Last Updated 03/01/2023
- H9706009
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Pharmacy Directory – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H8554001
Sherman and Ada Areas
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Value (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory –Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Value (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
South Texas Area
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
The Valley Area
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Value (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
Tyler and Longview Areas
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
Victoria Area
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Protect (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MA) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MA) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Medical Providers
Other
Waco, Temple, and Bryan Areas
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 11/17/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Choice Premier (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- H4801010
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- H4801011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H4801010
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H4801011
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H4801010
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) Addendum – Last Updated 03/01/2023
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Onlin