Medicare Advantage Dual Care Plan Documents
Find the documents you need to help you manage your Medicare Advantage prescription drug offered by Blue Cross and Blue Shield of Texas.
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Blue Cross Medicare Advantage Dual Care Plus (HMO SNP)SM
General Plan Information- Annual Notice of Change (HMO SNP) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (HMO SNP) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO SNP) – Last Updated 09/30/2022
- Evidence of Coverage (HMO SNP) – Last Updated 09/30/2022
- Low Income Premium Subsidy (HMO SNP) – Last Updated 09/30/2022
- Plan Star Rating (HMO SNP) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
- Medicare Individual DSNP Summary - Last Updated 01/23/2023
Prescription Drug Information
- Drug Formulary (HMO SNP) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO SNP)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (HMO SNP) – Last Updated 09/30/2022
Other
General Plan Information- Annual Notice of Change (HMO SNP) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (HMO SNP) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO SNP) – Last Updated 09/30/2022
- Evidence of Coverage (HMO SNP) – Last Updated 09/30/2022
- Low Income Premium Subsidy (HMO SNP) – Last Updated 09/30/2022
- Plan Star Rating (HMO SNP) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO SNP) – Last Updated 03/01/2023
- Find a Pharmacy
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Pharmacy Directory – Last Updated 03/01/2023
- Prescription Drug Coverage Determination Request Form (HMO SNP)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (HMO SNP) – Last Updated 09/30/2022
Other
Last Updated: March 10, 2023
Last Updated: 09302022
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