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.
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
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
Medicare & Medicaid Forms
Request for Medicare Prescription Drug Coverage Determination
Request for Redetermination of Medicare Prescription Drug Denial
Utilization Management Forms
Prior Authorization Criteria and Form
Quantity Limits Exception Form
Step Therapy Criteria and Form
View these forms and documents in Spanish. If you have questions, please Contact Us.