Forms and Documents

Find the forms and documents you need to manage your Blue Cross Community MMAI (Medicare-Medicaid Plan)SM offered by Blue Cross and Blue Shield of Illinois.

2021 Plan Documents

2021 Annual Notice of Changes English | Spanish

2021 Member Handbook (includes document of coverage information) English | Spanish

2021 Drug List (Formulary) English | Spanish

2021 Provider and Pharmacy Directory English | Spanish

2021 Summary of Benefits English | Spanish

Privacy Documents

Critical Incident Form for Members English | Spanish

AllianceRx Walgreens Prime Mail-Order Form English | Spanish

Express Scripts® Pharmacy Mail-Order Form English | Spanish

Frequently Asked Questions English | Spanish

HIPAA Notice of Privacy Practices English | Spanish

Prescription Drug Transition Policy English | Spanish

Power of Attorney

Appointment of Representative English | Spanish

Quality Improvement Form English | Spanish

Medicare & Medicaid Forms

Utilization Management Forms

2022 Plan Documents

2022 Annual Notice of Changes English | Spanish

2022 Member Handbook (includes document of coverage information) English | Spanish

2022 Drug List (Formulary) English | Spanish

2022 Provider and Pharmacy Directory English | Spanish

2022 Summary of Benefits English | Spanish

Privacy Documents

Critical Incident Form for Members English | Spanish

AllianceRx Walgreens Prime Mail-Order Form English | Spanish

Express Scripts® Pharmacy Mail-Order Form English | Spanish

Drug Mail Order Form English | Spanish

Frequently Asked Questions English | Spanish

HIPAA Notice of Privacy Practices English | Spanish

Prescription Drug Transition Policy English | Spanish

Power of Attorney

Appointment of Representative English | Spanish

Quality Improvement Form English | Spanish

Medicare & Medicaid Forms

Utilization Management Forms