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.
-
Blue Cross Medicare Advantage Value (HMO)
2019 Annual Notice of Change Value (HMO) English | español
2019 Evidence of Coverage Value (HMO) English | español
2019 Summary of Benefits Value (HMO) English | español
2019 Enrollment Form Value (HMO) English | español
2019 Plan Star Rating Value (HMO) English | español
2019 Drug Formulary Value (HMO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Provider Directory Value (HMO) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Directory Online Request Form English | español
2019 Low Income Premium Subsidy (HMO) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Austin and Surrounding Areas
-
Blue Cross Medicare Advantage Basic (HMO)
2019 Austin Annual Notice of Change Basic (HMO) English | español
2019 Austin Evidence of Coverage Basic (HMO) English | español
2019 Austin Summary of Benefits Basic (HMO) English | español
2019 Austin Enrollment Form (HMO) English | español
2019 Plan Star Rating Basic (HMO) English | español
2019 Austin Drug Formulary Basic (HMO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Provider Directory Basic (HMO) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Directory Online Request Form English | español
2019 Low Income Premium Subsidy (HMO) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
-
Blue Cross Medicare Advantage Choice Plus (PPO)
2019 Austin Annual Notice of Change Choice Plus (PPO) English | español
2019 Austin Evidence of Coverage Choice Plus (PPO) English | español
2019 Austin Summary of Benefits Choice Plus (PPO) English | español
2019 Enrollment Form (PPO) English | español
2019 Plan Star Rating (PPO) English | español
2019 Drug Formulary (PPO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Provider Directory (PPO) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Directory Online Request Form English | español
2019 Low Income Premium Subsidy (PPO) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
-
Blue Cross Medicare Advantage Choice Premier (PPO)
2019 Austin Annual Notice of Change Choice Premier (PPO) English | español
2019 Austin Evidence of Coverage Choice Premier (PPO) English | español
2019 Austin Summary of Benefits Choice Premier (PPO) English | español
2019 Enrollment Form (PPO) English | español
2019 Plan Star Rating (PPO) English | español
2019 Drug Formulary (PPO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Austin Provider Directory (PPO) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Directory Online Request Form English | español
2019 Low Income Premium Subsidy (PPO) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Dallas and Surrounding Areas
-
Blue Cross Medicare Advantage Choice Plus (PPO)
2019 Dallas Annual Notice of Change Choice Plus (PPO) English | español
2019 Dallas Evidence of Coverage Choice Plus (PPO) English | español
2019 Dallas Summary of Benefits Choice Plus (PPO) English | español
2019 Enrollment Form (PPO) English | español
2019 Plan Star Rating (PPO) English | español
2019 Drug Formulary (PPO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Dallas 2019 Provider Directory (PPO) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Directory Online Request Form English | español
2019 Low Income Premium Subsidy (PPO) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (MAPD)
-
Blue Cross Medicare Advantage Choice Premier (PPO)
2019 Dallas Annual Notice of Change Choice Premier (PPO) English | español
2019 Dallas Evidence of Coverage Choice Premier (PPO) English | español
2019 Dallas Summary of Benefits Choice Premier (PPO) English | español
2019 Enrollment Form (PPO) English | español
2019 Plan Star Rating (PPO) English | español
2019 Drug Formulary (PPO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Dallas 2019 Provider Directory (PPO) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Directory Online Request Form English | español
2019 Low Income Premium Subsidy (PPO) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (MAPD)
2019 El Paso and Surrounding Areas
-
Blue Cross Medicare Advantage Basic (HMO)
2019 El Paso Annual Notice of Change Basic (HMO) English | español
2019 El Paso Evidence of Coverage Basic (HMO) English | español
2019 El Paso Summary of Benefits Basic (HMO) English | español
2019 El Paso Enrollment Form (HMO) English | español
2019 Plan Star Rating Basic (HMO) English | español
2019 Drug Formulary Basic (HMO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Provider Directory Basic (HMO) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Directory Online Request Form English | español
2019 Low Income Premium Subsidy (HMO) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Houston and Surrounding Areas
-
Blue Cross Medicare Advantage Basic (HMO)
2019 Houston Annual Notice of Change Basic (HMO) English | español
2019 Houston Evidence of Coverage Basic (HMO) English | español
2019 Houston Summary of Benefits Basic (HMO) English | español
2019 Houston Enrollment Form (HMO) English | español
2019 Plan Star Rating Basic (HMO) English | español
2019 Drug Formulary Basic (HMO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Provider Directory Basic (HMO) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Directory Online Request Form English | español
2019 Low Income Premium Subsidy (HMO) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (MAPD)
-
Blue Cross Medicare Advantage Choice Plus (PPO)
2019 Houston Annual Notice of Change Choice Plus (PPO) English | español
2019 Houston Evidence of Coverage Choice Plus (PPO) English | español
2019 Houston Summary of Benefits Choice Plus (PPO) English | español
2019 Enrollment Form (PPO) English | español
2019 Plan Star Rating (PPO) English | español
2019 Drug Formulary (PPO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Houston Provider Directory (PPO) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Directory Online Request Form English | español
2019 Low Income Premium Subsidy (PPO) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (MAPD)
-
Blue Cross Medicare Advantage Choice Premier (PPO)
2019 Houston Annual Notice of Change Choice Premier (PPO) English | español
2019 Houston Evidence of Coverage Choice Premier (PPO) English | español
2019 Houston Summary of Benefits Choice Premier (PPO) English | español
2019 Enrollment Form (PPO) English | español
2019 Plan Star Rating (PPO) English | español
2019 Drug Formulary (PPO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Houston Provider Directory (PPO) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Directory Online Request Form English | español
2019 Low Income Premium Subsidy (PPO) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (MAPD)
2019 San Antonio and Surrounding Areas
-
Blue Cross Medicare Advantage Choice Plus (PPO)
2019 San Antonio Annual Notice of Change Choice Plus (PPO) English | español
2019 San Antonio Evidence of Coverage Choice Plus (PPO) English | español
2019 Summary of Benefits (PPO) English | español
2019 Enrollment Form (PPO) English | español
2019 Plan Star Rating (PPO) English | español
2019 Drug Formulary Plus and Premier (PPO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 San Antonio 2019 Provider Directory (PPO) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Directory Online Request Form English | español
2019 Low Income Premium Subsidy (PPO) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (MAPD)
2019 South Texas and Surrounding Areas
-
Blue Cross Medicare Advantage Basic (HMO)
2019 South Texas Annual Notice of Change Basic (HMO) English | español
2019 South Texas Evidence of Coverage Basic (HMO) English | español
2019 South Texas Summary of Benefits Basic (HMO) English | español
2019 South Texas Enrollment Form (HMO) English | español
2019 Plan Star Rating Basic (HMO) English | español
2019 Drug Formulary Basic (HMO) English | español
2019 Pharmacy Directory (HMO/HMO-POS/PPO) English | español
2019 Provider Directory Basic (HMO) English | español
2019 Dental, Hearing and Vision Provider Directories English | español
2019 Directory Online Request Form English | español
2019 Low Income Premium Subsidy (HMO) English | español
2019 Prescription Drug Transition Policy (MAPD) English | español
2019 Prescription Drug Coverage Determination Request Form (MAPD)
2019 Online Coverage Determination Request Form
2019 Prescription Drug Coverage Redetermination Request Form (MAPD)
2019 Online Coverage Redetermination Request Form
2019 Automated Premium Payment (ACH) Form (MAPD)
Last Updated: 09302018
Y0096_WEB_TX_MM19 Accepted
Last Updated: 09302018
Y0096_WEB_TX_MM19 Accepted