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.
2020 Austin and Surrounding Areas
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Blue Cross Medicare Advantage Basic (HMO)
2020 Austin Annual Notice of Change Basic (HMO) English | español
2020 Austin Evidence of Coverage Basic (HMO) English | español
2020 Austin Summary of Benefits Basic (HMO) English | español
2020 Austin Enrollment Form (HMO) English | español
2020 Plan Star Rating Basic (HMO) English | español
2020 Austin Drug Formulary Basic (HMO) English | español
2020 Find a Pharmacy English | español
2020 Find a Doctor or Hospital English | español
2020 Low Income Premium Subsidy (HMO) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Value (HMO)
2020 Austin Evidence of Coverage Value (HMO) English | español
2020 Austin Summary of Benefits Value (HMO) English | español
2020 Austin Enrollment Form (HMO) English | español
2020 Plan Star Rating Value (HMO) English | español
2020 Drug Formulary Value (HMO) English | español
2020 Find a Pharmacy English | español
2020 Find a Doctor or Hospital English | español
2020 Low Income Premium Subsidy (HMO) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)
2020 Austin Annual Notice of Change Choice Plus (PPO) English | español
2020 Austin Evidence of Coverage Choice Plus (PPO) English | español
2020 Austin Summary of Benefits Choice Plus (PPO) English | español
2020 Enrollment Form (PPO) English | español
2020 Plan Star Rating (PPO) English | español
2020 Drug Formulary (PPO) English | español
2020 Find a Pharmacy English | español
2020 Find a Doctor or Hospital English | español
2020 Low Income Premium Subsidy (PPO) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Premier (PPO)
2020 Austin Annual Notice of Change Choice Premier (PPO) English | español
2020 Austin Evidence of Coverage Choice Premier (PPO) English | español
2020 Austin Summary of Benefits Choice Premier (PPO) English | español
2020 Enrollment Form (PPO) English | español
2020 Plan Star Rating (PPO) English | español
2020 Drug Formulary (PPO) English | español
2020 Find a Pharmacy English | español
2020 Find a Doctor or Hospital English | español
2020 Low Income Premium Subsidy (PPO) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
2020 Dallas and Surrounding Areas
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Blue Cross Medicare Advantage Value (HMO)
2020 Dallas Evidence of Coverage Value (HMO) English | español
2020 Dallas Summary of Benefits Value (HMO) English | español
2020 Enrollment Form (HMO) English | español
2020 Plan Star Rating Value (HMO) English | español
2020 Plan Star Rating Basic (HMO) English | español
2020 Drug Formulary (HMO) English | español
2020 Find a Pharmacy English | español
2020 Find a Doctor or Hospital English | español
2020 Low Income Premium Subsidy (HMO) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)
2020 Dallas Annual Notice of Change Choice Plus (PPO) English | español
2020 Dallas Evidence of Coverage Choice Plus (PPO) English | español
2020 Dallas Summary of Benefits Choice Plus (PPO) English | español
2020 Enrollment Form (PPO) English | español
2020 Plan Star Rating (PPO) English | español
2020 Drug Formulary (PPO) English | español
2020 Find a Pharmacy English | español
2020 Find a Doctor or Hospital English | español
2020 Low Income Premium Subsidy (PPO) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Premier (PPO)
2020 Dallas Annual Notice of Change Choice Premier (PPO) English | español
2020 Dallas Evidence of Coverage Choice Premier (PPO) English | español
2020 Dallas Summary of Benefits Choice Premier (PPO) English | español
2020 Enrollment Form (PPO) English | español
2020 Plan Star Rating (PPO) English | español
2020 Drug Formulary (PPO) English | español
2020 Find a Pharmacy English | español
2020 Find a Doctor or Hospital English | español
2020 Low Income Premium Subsidy (PPO) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
2020 El Paso and Surrounding Areas
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Blue Cross Medicare Advantage Basic (HMO)
2020 El Paso Annual Notice of Change Basic (HMO) English | español
2020 El Paso Evidence of Coverage Basic (HMO) English | español
2020 El Paso Summary of Benefits Basic (HMO) English | español
2020 El Paso Enrollment Form (HMO) English | español
2020 Plan Star Rating Basic (HMO) English | español
2020 Drug Formulary Basic (HMO) English | español
2020 Find a Pharmacy English | español
2020 Find a Doctor or Hospital English | español
2020 Low Income Premium Subsidy (HMO) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
2020 Houston and Surrounding Areas
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Blue Cross Medicare Advantage Basic (HMO)
2020 Houston Annual Notice of Change Basic (HMO) English | español
2020 Houston Evidence of Coverage Basic (HMO) English | español
2020 Houston Summary of Benefits Basic (HMO) English | español
2020 Houston Enrollment Form (HMO) English | español
2020 Plan Star Rating Basic (HMO) English | español
2020 Drug Formulary Basic (HMO) English | español
2020 Find a Pharmacy English | español
2020 Find a Doctor or Hospital English | español
2020 Low Income Premium Subsidy (HMO) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)
2020 Houston Annual Notice of Change Choice Plus (PPO) English | español
2020 Houston Evidence of Coverage Choice Plus (PPO) English | español
2020 Houston Summary of Benefits Choice Plus (PPO) English | español
2020 Enrollment Form (PPO) English | español
2020 Plan Star Rating (PPO) English | español
2020 Drug Formulary (PPO) English | español
2020 Find a Pharmacy English | español
2020 Find a Doctor or Hospital English | español
2020 Low Income Premium Subsidy (PPO) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Premier (PPO)
2020 Houston Annual Notice of Change Choice Premier (PPO) English | español
2020 Houston Evidence of Coverage Choice Premier (PPO) English | español
2020 Houston Summary of Benefits Choice Premier (PPO) English | español
2020 Enrollment Form (PPO) English | español
2020 Plan Star Rating (PPO) English | español
2020 Drug Formulary (PPO) English | español
2020 Find a Pharmacy English | español
2020 Find a Doctor or Hospital English | español
2020 Low Income Premium Subsidy (PPO) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
2020 San Antonio and Surrounding Areas
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Blue Cross Medicare Advantage Value (HMO)
2020 Annual Notice of Change Value (HMO) English | español
2020 Evidence of Coverage Value (HMO) English | español
2020 Summary of Benefits Value (HMO) English | español
2020 Enrollment Form Value (HMO) English | español
2020 Plan Star Rating Basic (HMO) English | español
2020 Drug Formulary Value (HMO) English | español
2020 Find a Pharmacy English | español
2020 Find a Doctor or Hospital English | español
2020 Low Income Premium Subsidy (HMO) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
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Blue Cross Medicare Advantage Choice Plus (PPO)
2020 San Antonio Annual Notice of Change Choice Plus (PPO) English | español
2020 San Antonio Evidence of Coverage Choice Plus (PPO) English | español
2020 Summary of Benefits (PPO) English | español
2020 Enrollment Form (PPO) English | español
2020 Plan Star Rating (PPO) English | español
2020 Drug Formulary (PPO) English | español
2020 Find a Pharmacy English | español
2020 Find a Doctor or Hospital English | español
2020 Low Income Premium Subsidy (PPO) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
2020 South Texas and Surrounding Areas
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Blue Cross Medicare Advantage Basic (HMO)
2020 South Texas Annual Notice of Change Basic (HMO) English | español
2020 South Texas Evidence of Coverage Basic (HMO) English | español
2020 South Texas Summary of Benefits Basic (HMO) English | español
2020 South Texas Enrollment Form (HMO) English | español
2020 Plan Star Rating Basic (HMO) English | español
2020 Drug Formulary Basic (HMO) English | español
2020 Find a Pharmacy English | español
2020 Find a Doctor or Hospital English | español
2020 Low Income Premium Subsidy (HMO) English | español
2020 Prescription Drug Transition Policy (MAPD) English | español
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Online Coverage Determination Request Form
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Online Coverage Redetermination Request Form
2020 Automated Premium Payment (ACH) Form (MAPD)
Last Updated: 12312019
Y0096_WEBTXMM20
Last Updated: 12312019
Y0096_WEBTXMM20