Documents & forms

Medicare Advantage plan materials

Thank you for being a Medicare Advantage member! For your convenience, the links below give you access to important plan materials for all of our plans in one place.

If you have questions about your plan, please call the Medicare Concierge Team.

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Documents
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Group Forms

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BlueCHiP for Medicare Access
Annual Notice of Changes (ANOC)
Evidence of Coverage
Enrollment Application – Duals and Access
Enrollment E-Book (coming soon)
Medicare Advantage Plan Highlights (coming soon)
Summary of Benefits

BlueCHiP for Medicare Extra
Annual Notice of Changes (ANOC)
Evidence of Coverage
Enrollment Application
Enrollment E-Book (coming soon)
Medicare Advantage Plan Highlights
Summary of Benefits

BlueCHiP for Medicare Enhanced
Annual Notice of Changes (ANOC)
Evidence of Coverage
Enrollment Application
Enrollment E-Book (coming soon)
Medicare Advantage Plan Highlights
Summary of Benefits

BlueCHiP for Medicare Essential
Annual Notice of Changes (ANOC)
Evidence of Coverage
Enrollment Application
Enrollment E-Book (coming soon)
Medicare Advantage Plan Highlights
Summary of Benefits

BlueCHiP for Medicare Core
Annual Notice of Changes (ANOC)
Evidence of Coverage
Enrollment Application
Enrollment E-Book (coming soon)
Medicare Advantage Plan Highlights
Summary of Benefits

BlueRI for Duals
Annual Notice of Changes (ANOC)
Evidence of Coverage
Enrollment E-Book (coming soon)
Enrollment Application – Duals and Access
Medicare Advantage Plan Highlights (coming soon)
Summary of Benefits
Provider Directory
Plan Ratings (coming soon)
Quality Improvement Process

Forms

Enrollment, plan change, and other forms that BCBSRI Medicare members might need.

Appointment of Representative
Blue Medicare Rx Site
BlueCHiP for Medicare (HMO) Medicare Advantage with Prescription Drug Coverage Disenrollment Form
Confidential Communication Form
Enrollment Application
Enrollment Application – Duals and Access
EyeMed Out-of-Network Vision Hardware Claim Form
EyeMed Out-of-Network Vision Hardware Claim Form Guide
Home Delivery Order Form Express Scripts
Home Delivery Order Form Walgreen's Mail Service
Home Delivery Ordering Instructions Amazon Pharmacy
Medicare Advantage Payment Option Form
Medicare Advantage Prescription Drug Claim Form
Medicare Complaint
Member Representative Designation
Plan Change
Scope of Appointment

Documents for BlueCHiP for Medicare Plans

These documents cover multiple Medicare plans, but specific coverage and benefits vary by plan. Please check your Summary of Benefits or contact the Medicare Concierge Team for guidance.

Comprehensive Formulary
Medicare Advantage Pharmacy Directory
Provider Directory
OTC and Grocery Catalog (coming soon)
OTC Catalog (coming soon)
Fitness Benefits (coming soon)
Fitness Tier Directory (coming soon)
Low-Income Subsidy Premium Summary (coming soon)
Medicare Advantage Plan Ratings (coming soon)
Medical Drug Review Drug Listing

Pharmacy documents

These documents apply to all BCBSRI Medicare Advantge plans. If you are looking for a specific prescription drug, you don't need to scroll through the formulary document. You can look it up on myPrime, which you will find when you log in to your myBCBSRI account.

CMS Best Available Evidence Page
Frequently Asked Questions About Prescription Drug Coverage
Medicare Advantage Part D Exceptions and Appeals Information
Medicare Advantage Prescription Drug Claim Form
Medicare Part D Coverage Determination and Redetermination Information
Medicare Part D Coverage Determination Online Request Form
Medicare Part D Coverage Redetermination Online Request Form
Medication Therapy Management Program
Plan Transition Policy for Prescription Drugs
Prescription Payment Plan
Prior Authorization Criteria
Quantity Limits
Step Therapy Criteria

General documents

These apply to every BCBSRI Medicare member, regardless of plan.

Advance Directives
Appeals and Grievances Data Report
Contract Disclaimers
Coverage for New Medical Technologies
Frequently Asked Premium Billing Questions
Grievance and Appeals Facts
Medicare Ombudsman Website
Medicare Resources
Member Rights & Responsibilities
Multi-Language Interpreter Services
Notice of Privacy Practices

Group Medicare documents

These apply to every BCBSRI Group Medicare member.

HealthMate Coast-to-Coast for Medicare Group 1 - Prior Authorization Criteria
HealthMate Coast-to-Coast for Medicare Group 1 - Quantity Limits
HealthMate Coast-to-Coast for Medicare Group 1 - Step Therapy Criteria
HealthMate Coast-to-Coast for Medicare Group 2-9 - Prior Authorization Criteria
HealthMate Coast-to-Coast for Medicare Group 2-9 - Quantity Limits
HealthMate Coast-to-Coast for Medicare Group 2-9 - Step Therapy Criteria
HealthMate Coast-to-Coast for Medicare Group 10 - Prior Authorization Criteria
HealthMate Coast-to-Coast for Medicare Group 10 - Quantity Limits
HealthMate Coast-to-Coast for Medicare Group 10 - Step Therapy Criteria
HealthMate Coast-to-Coast for Medicare Group Pharmacy Directory
Healthmate for Medicare Group PPO - Provider Directory
Healthmate for Medicare - Plan Ratings (coming soon)
Medicare Advantage Group - Formulary
Medicare Advantage Group - Prior Authorization Criteria
Medicare Advantage Group - Quantity Limits
Medicare Advantage Group - Step Therapy Criteria
Medicare Advantage Group Pharmacy Directory