Plan Documents

Blue Cross Medicare Advantage
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The following documents can help you get more information about this Medicare Prescription Drug plan, enroll in a plan and more.


General Plan Information 
Annual Notice of Change Basic (HMO) English PDF Document 
en Espanol PDF Document
Annual Notice of Change Premier (HMO) English PDF Document 
en Espanol PDF Document
Lovelace Annual Notice of Change Basic $0 (HMO) English PDF Document 
en Espanol PDF Document
Lovelace Annual Notice of Change Enhanced (HMO-POS) English PDF Document 
en Espanol PDF Document
Annual Notice of Change Choice (PPO) English PDF Document 
en Espanol PDF Document
Evidence of Coverage Basic (HMO) English PDF Document 
en Espanol PDF Document
Evidence of Coverage Premier (HMO) English PDF Document 
en Espanol PDF Document
Lovelace Evidence of Coverage Basic $0 (HMO) English PDF Document 
en Espanol PDF Document
Lovelace Evidence of Coverage Enhanced (HMO) English PDF Document 
en Espanol PDF Document
Evidence of Coverage Choice Plus (PPO) English PDF Document 
en Espanol PDF Document
Summary of Benefits (HMO)  English PDF Document 
en Espanol PDF Document
Lovelace Summary of Benefits (HMO/HMO-POS) English PDF Document 
en Espanol PDF Document
Summary of Benefits (PPO) English PDF Document 
en Espanol PDF Document
Prescription Drug Forms
Mail- Order Physician New Prescription Fax Form External Link
Lovelace Mail- Order Physician New Prescription Fax Form PDF Document
Pharmacy Mail-Order Form External Link
Lovelace Pharmacy Mail-Order Form PDF Document
Prescription Drug Claim Form (HMO) External Link 
Lovelace Prescription Drug Claim Form (HMO) PDF Document 
Lovelace Prescription Drug Claim Form (HMO-POS) PDF Document
Prescription Drug Claim Form (PPO) External Link
Medicare Part B vs. Part D Form External Link 
Lovelace Medicare Part B vs. Part D Form PDF Document 
Additional Resources 
Authorization to Disclose Protected Health Information (PHI) Form PDF Document 
Lovelace Authorization to Disclose Protected Health Information (PHI) Form PDF Document 
Automated Premium Payment (ACH) Form PDF Document 
Lovelace Automated Premium Payment (ACH) Form PDF Document 
CMS Appointment of Representative Form PDF Document
Lovelace CMS Appointment of Representative Form PDF Document
Multi-language Interpreter Services PDF Document
Lovelace Multi-language Interpreter Services PDF Document
Lovelace Direct Member Reimbursement Form PDF Document 
Notice of Privacy Practices PDF Document
Lovelace Notice of Privacy Practices PDF Document