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.
View these forms and documents in Spanish. If you have questions, please Contact Us.
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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
Prescription Drug Information
- Drug Formulary (HMO SNP) – Last Updated 11/08/2022
- 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 11/08/2022
- 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 11/08/2022
- 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 11/08/2022
- 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
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Blue Cross Medicare Advantage Dual Care Plus (HMO SNP)SM
2022 Annual Notice of Change Dual Care Plus (HMO SNP) English | español
2022 Evidence of Coverage Dual Care Plus (HMO SNP) English | español
2022 Summary of Benefits Dual Care Plus (DSNP) English | español
2022 Enrollment Form Dual Care Plus (HMO SNP) English | español
2022 Plan Star Rating (HMO SNP) English | español
2022 Drug Formulary Dual Care Plus (HMO SNP) English | español
2022 Pharmacy Directory English | español
2022 Find a Doctor or Hospital English | español
2022 Low Income Premium Subsidy (HMO SNP) English | español
2022 Prescription Drug Transition Policy (HMO SNP) English | español
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (HMO SNP) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (HMO SNP) English | español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (DSNP)
Last Updated: Nov. 08, 2022
Last Updated: 09302022
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