Medicare plan documents
Find plan documents including provider directories, benefits overviews, enrollment forms and more.
Documents
Documents for Medicare plans
Medicare Advantage (PPO) - Metro Region
Medicare Advantage (PPO) - West Region
Medicare Advantage (PPO) - Southern MN
Freedom Blue Medicare Advantage (PPO)
Platinum Blue℠ (Cost)
Group Medicare plans
MedicareBlue℠ Rx (PDP)
Get plan overview, documents, pharmacies and coverage.
- Medicare complaint form
- Filing a complaint, appeal or grievance
- Worldwide Emergency or Urgent Care Benefit Claim form
- Medicare deductibles, copayments and premium
- Medicare formulary transition policy
- Best available evidence policy
- Appointment of representative
- Provider payment methods
- Privacy policy
- Multi-language interpreter services
- Notice of nondiscrimination
- Women's health & cancer rights
- Authorization for disclosure of health information form - English
- Authorization for disclosure of health information form - Hmong
- Authorization for disclosure of health information form - Spanish
- Power of attorney form
Rights and responsibilities upon disenrollment
When you leave or end your membership in Blue Cross Medicare plans it's called a disenrollment. A voluntary disenrollment is when you decide to leave the plan. You can do this only at certain times of the year, such as if you want to change to another plan during the annual enrollment period. An involuntary disenrollment is when the plan must end your membership. An example of this type of disenrollment is if you do not pay the plan's premiums.
If you are disenrolled for any reason, the plan will notify you of the date your membership will end and the reason for it ending. If you have questions about disenrollment, please call Customer Service at the back of your member ID card.
Order documents
Ordering plan documents
You can order plan documents to be mailed to you.
Order a provider directory, dental directory, annual notice of change or evidence of coverage
Order enrollment packets that include benefit summaries and formularies (drug lists)
Learn more
Medicare Decision Guide
Use this guide to help you choose a health plan the fits your needs.
Star Ratings
Star Ratings measure the quality of Medicare plans.
Blue Cross offers Cost, PPO and PDP plans with Medicare contracts. Enrollment in these Blue Cross plans depends on contract renewal. Plans are available to residents of the service area. You may only be able to enroll in a plan at certain times of the year. You must continue to pay your Medicare Part B premium. This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. For more information contact the plan. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Call 1 (877) 334-7781 (TTY 711) 8 a.m. to 8 p.m., daily.
SilverSneakers® is a registered trademark of Tivity Health, Inc., an independent company that provides health and fitness programs. Blue Cross Medicare Advantage, Platinum Blue, Senior Gold and other Medicare Supplement and SecureBlue plans are eligible.
Every year, Medicare evaluates plans based on a 5-star rating system.
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