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.
2021 Austin and Surrounding Areas
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Blue Cross Medicare Advantage Value (HMO)
2021 Austin Annual Notice of Change Value (HMO) English | español
2021 Austin Evidence of Coverage Value (HMO) English | español
2021 Austin Summary of Benefits Value (HMO) English | español
2021 Austin Enrollment Form (HMO) English | español
2021 Plan Star Rating - Plan too new to be measured
2021 Drug Formulary Value (HMO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (HMO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (HMO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (HMO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)
2021 Austin Annual Notice of Change Choice Plus (PPO) English | español
2021 Austin Evidence of Coverage Choice Plus (PPO) English | español
2021 Austin Summary of Benefits Choice Plus (PPO) English | español
2021 Plan Star Rating (PPO) English | español
2021 Enrollment Form (PPO) English | español
2021 Drug Formulary (PPO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (PPO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Premier (PPO)
2021 Austin Annual Notice of Change Choice Premier (PPO) English | español
2021 Austin Evidence of Coverage Choice Premier (PPO) English | español
2021 Austin Summary of Benefits Choice Premier (PPO) English | español
2021 Plan Star Rating (PPO) English | español
2021 Enrollment Form (PPO) English | español
2021 Drug Formulary (PPO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (PPO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
2021 Dallas and Surrounding Areas
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Blue Cross Medicare Advantage Value (HMO)
2021 Dallas Annual Notice of Change Value (HMO) English | español
2021 Dallas Evidence of Coverage Value (HMO) English | español
2021 Dallas Summary of Benefits Value (HMO) English | español
2021 Enrollment Form (HMO) English | español
2021 Plan Star Rating - Plan too new to be measured
2021 Drug Formulary (HMO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (HMO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (HMO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (HMO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)
2021 Dallas Annual Notice of Change Choice Plus (PPO) English | español
2021 Dallas Evidence of Coverage Choice Plus (PPO) English | español
2021 Dallas Summary of Benefits Choice Plus (PPO) English | español
2021 Plan Star Rating (PPO) English | español
2021 Enrollment Form (PPO) English | español
2021 Drug Formulary (PPO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (PPO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Premier (PPO)
2021 Dallas Annual Notice of Change Choice Premier (PPO) English | español
2021 Dallas Evidence of Coverage Choice Premier (PPO) English | español
2021 Dallas Summary of Benefits Choice Premier (PPO) English | español
2021 Plan Star Rating (PPO) English | español
2021 Enrollment Form (PPO) English | español
2021 Drug Formulary (PPO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (PPO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
2021 El Paso and Surrounding Areas
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Blue Cross Medicare Advantage Basic (HMO)
2021 El Paso Annual Notice of Change Basic (HMO) English | español
2021 El Paso Evidence of Coverage Basic (HMO) English | español
2021 El Paso Summary of Benefits Basic (HMO) English | español
2021 Plan Star Rating (HMO) English | español
2021 El Paso Enrollment Form (HMO) English | español
2021 Drug Formulary Basic (HMO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (HMO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (HMO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (HMO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Value (HMO)
2021 Annual Notice of Change Value (HMO) English | español
2021 Evidence of Coverage Value (HMO) English | español
2021 Summary of Benefits Value (HMO) English | español
2021 Plan Star Rating (HMO) English | español
2021 Enrollment Form Value (HMO) English | español
2021 Drug Formulary Value (HMO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (HMO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (HMO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (HMO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plan (PPO)
2021 El Paso Evidence of Coverage Choice Plus (PPO) English | español
2021 El Paso Summary of Benefits (PPO) English | español
2021 El Paso Enrollment Form (PPO) English | español
2021 Plan Star Rating (PPO) English | español
2021 Drug Formulary (PPO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (PPO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
2021 Houston and Surrounding Areas
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Blue Cross Medicare Advantage Basic (HMO)
2021 Houston Annual Notice of Change Basic (HMO) English | español
2021 Houston Evidence of Coverage Basic (HMO) English | español
2021 Houston Summary of Benefits Basic (HMO) English | español
2021 Plan Star Rating (HMO) English | español
2021 Houston Enrollment Form (HMO) English | español
2021 Drug Formulary Basic (HMO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (HMO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (HMO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (HMO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)
2021 Houston Annual Notice of Change Choice Plus (PPO) English | español
2021 Houston Evidence of Coverage Choice Plus (PPO) English | español
2021 Houston Summary of Benefits Choice Plus (PPO) English | español
2021 Plan Star Rating (PPO) English | español
2021 Enrollment Form (PPO) English | español
2021 Drug Formulary (PPO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (PPO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Premier (PPO)
2021 Houston Annual Notice of Change Choice Premier (PPO) English | español
2021 Houston Evidence of Coverage Choice Premier (PPO) English | español
2021 Houston Summary of Benefits Choice Premier (PPO) English | español
2021 Plan Star Rating (PPO) English | español
2021 Enrollment Form (PPO) English | español
2021 Drug Formulary (PPO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (PPO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
2021 San Antonio and Surrounding Areas
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Blue Cross Medicare Advantage Value (HMO)
2021 Annual Notice of Change Value (HMO) English | español
2021 Evidence of Coverage Value (HMO) English | español
2021 Summary of Benefits Value (HMO) English | español
2021 Plan Star Rating (HMO) English | español
2021 Enrollment Form Value (HMO) English | español
2021 Drug Formulary Value (HMO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (HMO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (HMO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (HMO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)
2021 San Antonio Annual Notice of Change Choice Plus (PPO) English | español
2021 San Antonio Evidence of Coverage Choice Plus (PPO) English | español
2021 Summary of Benefits (PPO) English | español
2021 Plan Star Rating (PPO) English | español
2021 Enrollment Form (PPO) English | español
2021 Drug Formulary (PPO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (PPO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
2021 South Texas and Surrounding Areas
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Blue Cross Medicare Advantage Basic (HMO)
2021 South Texas Annual Notice of Change Basic (HMO) English | español
2021 South Texas Evidence of Coverage Basic (HMO) English | español
2021 South Texas Summary of Benefits Basic (HMO) English | español
2021 Plan Star Rating (HMO) English | español
2021 South Texas Enrollment Form (HMO) English | español
2021 Drug Formulary Basic (HMO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (HMO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (HMO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (HMO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
-
Blue Cross Medicare Advantage Value (HMO)
2021 Annual Notice of Change Value (HMO) English | español
2021 Evidence of Coverage Value (HMO) English | español
2021 Summary of Benefits Value (HMO) English | español
2021 Plan Star Rating (HMO) English | español
2021 Enrollment Form Value (HMO) English | español
2021 Drug Formulary Value (HMO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (HMO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (HMO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (HMO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)
2021 South Texas Evidence of Coverage Choice Plus (PPO) English | español
2021 South Texas Summary of Benefits (PPO) English | español
2021 Plan Star Rating (PPO) English | español
2021 South Texas Enrollment Form (PPO) English | español
2021 Drug Formulary (PPO) English | español
2021 Pharmacy Directory English | español
2021 Find a Doctor or Hospital English | español
2021 Low Income Premium Subsidy (PPO) English | español
2021 Prescription Drug Transition Policy (MAPD) English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Online Coverage Determination Request Form
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Online Coverage Redetermination Request Form
2021 Automated Premium Payment (ACH) Form (MAPD)
Last Updated: 12312020
Y0096_WEBTXMM21
Last Updated: 12312020
Y0096_WEBTXMM21