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 Illinois.
Chicago Area
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Blue Cross Medicare Advantage Basic (HMO)SM
2022 Annual Notice of Change Basic (HMO) English | español
2022 Evidence of Coverage Basic (HMO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (HMO) English | español
2022 Plan Star Rating (HMO) English | español
2022 Drug Formulary Basic (HMO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (HMO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Medicare Advocate Health (HMO)SM
2022 Annual Notice of Change Advocate Health (HMO) English | español
2022 Evidence of Coverage (HMO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (HMO) English | español
2022 Plan Star Rating (HMO) English | español
2022 Drug Formulary (HMO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (HMO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (HMO) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Basic Plus (HMO-POS)SM
2022 Annual Notice of Change Basic Plus (HMO-POS) English | español
2022 Evidence of Coverage Basic Plus (HMO-POS) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (HMO-POS) English | español
2022 Optional Supplemental Benefits Enrollment Form English | español
Current members should download, complete and submit this form to opt in for buy-up options.2022 Plan Star Rating (HMO) English | español
2022 Drug Formulary Basic Plus (HMO-POS) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (HMO-POS) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Premier Plus (HMO-POS)SM
2022 Annual Notice of Change Premier Plus (HMO-POS) English | español
2022 Evidence of Coverage Premier Plus (HMO-POS) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (HMO-POS) English | español
2022 Plan Star Rating (HMO) English | español
2022 Drug Formulary Premier Plus (HMO-POS) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (HMO-POS) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (HMO-POS) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)SM
2022 Annual Notice of Change Choice Plus (PPO) English | español
2022 Evidence of Coverage Choice Plus (PPO) English | español
2022 Summary of Benefits (PPO) English | español
2022 Enrollment Form (PPO) English | español
2022 Optional Supplemental Benefits Enrollment Form (PPO) English | español
Current members should download, complete and submit this form to opt in for buy-up options.2022 Plan Star Rating (PPO) English | español
2022 Drug Formulary Choice Plus (PPO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (PPO) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Premier (PPO)SM
2022 Annual Notice of Change Choice Premier (PPO) English | español
2022 Evidence of Coverage Choice Premier (PPO) English | español
2022 Summary of Benefits (PPO) English | espanol
2022 Enrollment Form (PPO) English | español
2022 Plan Star Rating (PPO) English | español
2022 Drug Formulary Choice Premier (PPO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (PPO) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Classic (PPO)SM
2022 Annual Notice of Change (PPO) English | español
2022 Evidence of Coverage Classic (PPO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (PPO) English | español
2022 Optional Supplemental Benefits Enrollment Form (PPO) English | español
Current members should download, complete and submit this form to opt in for buy-up options.2022 Drug Formulary Classic (PPO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Elite (PPO)SM
2022 Evidence of Coverage Elite (PPO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (PPO) English | español
2022 Optional Supplemental Benefits Enrollment Form (PPO) English | español
Current members should download, complete and submit this form to opt in for buy-up options.2022 Drug Formulary Elite (PPO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Flex (PPO)SM
2022 Evidence of Coverage Flex (PPO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (PPO) English | español
2022 Drug Formulary Flex (PPO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
Peoria Area
(includes Bloomington)
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Blue Cross Medicare Advantage Basic (HMO)SM
2022 Evidence of Coverage Basic (HMO)
Original Basic – English | español
New Basic – English | español2022 Summary of Benefits
Original Basic – English | español
New Basic – English | español2022 Enrollment Form (HMO)
Original Basic – English | español
New Basic – English | español2022 Optional Supplemental Benefits Enrollment Form (HMO)
Original Basic – English | español
Current members should download, complete and submit this form to opt in for buy-up options.2022 Drug Formulary Basic (HMO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (HMO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Classic (PPO)SM
2022 Evidence of Coverage Classic (PPO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (PPO) English | español
2022 Optional Supplemental Benefits Enrollment Form (PPO) English | español
Current members should download, complete and submit this form to opt in for buy-up options.2022 Plan Star Rating (PPO) English | español
2022 Drug Formulary Classic (PPO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Flex (PPO)SM
2022 Evidence of Coverage Flex (PPO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (PPO) English | español
2022 Drug Formulary Flex (PPO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
Rockford Area
(includes Davenport, Hannibal, Keokuk, Moline, Rock Island, and Quincy)
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Blue Cross Medicare Advantage Basic (HMO)SM
2022 Evidence of Coverage Basic (HMO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (HMO) English | español
2022 Drug Formulary Basic (HMO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (HMO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Classic (PPO)SM
2022 Evidence of Coverage Classic (PPO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (PPO) English | español
2022 Optional Supplemental Benefits Enrollment Form (PPO) English | español
Current members should download, complete and submit this form to opt in for buy-up options.2022 Drug Formulary Classic (PPO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Flex (PPO)SM
2022 Evidence of Coverage Flex (PPO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (PPO) English | español
2022 Drug Formulary Flex (PPO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
Saint Louis Area
(includes Paducah, Cape Girardeau, and Harrisburg)
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Blue Cross Medicare Advantage Basic (HMO)SM
2022 Evidence of Coverage Basic (HMO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (HMO) English | español
2022 Drug Formulary Basic (HMO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (HMO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Classic (PPO)SM
2022 Evidence of Coverage Classic (PPO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (PPO) English | español
2022 Optional Supplemental Benefits Enrollment Form (PPO) English | español
Current members should download, complete and submit this form to opt in for buy-up options.2022 Drug Formulary Classic (PPO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Flex (PPO)SM
2022 Evidence of Coverage Flex (PPO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (PPO) English | español
2022 Drug Formulary Flex (PPO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
Springfield Area
(includes Champaign and Decatur)
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Blue Cross Medicare Advantage Basic (HMO)SM
2022 Annual Notice of Change Basic (HMO) English | español
2022 Evidence of Coverage Basic (HMO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (HMO) English | español
2022 Optional Supplemental Benefits Enrollment Form (HMO) English | español
Current members should download, complete and submit this form to opt in for buy-up options.2022 Plan Star Rating (HMO) English | español
2022 Drug Formulary Basic (HMO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (HMO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)SM
2022 Annual Notice of Change Choice Plus (PPO) English | español
2022 Evidence of Coverage Choice Plus (PPO) English | español
2022 Summary of Benefits (PPO) English | español
2022 Enrollment Form (PPO) English | español
2022 Drug Formulary Choice Plus (PPO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (PPO) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Flex (PPO)SM
2022 Evidence of Coverage Flex (PPO) English | español
2022 Summary of Benefits English | español
2022 Enrollment Form (PPO) English | español
2022 Drug Formulary Flex (PPO) English | español
2022 Find a Doctor or Hospital English | español
2022 Pharmacy Directory English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
Last Updated: 02012022
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