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 New Mexico.
View these forms and documents in Spanish. If you have questions, please Contact Us.
Albuquerque and Santa Fe Areas
-
Blue Cross Medicare Advantage Basic (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – 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)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 11/17/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – 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)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- H1666012
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H8634002
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- H1666012
- Drug Formulary (PPO) – Last Updated 11/08/2022
- Find a Pharmacy
- Pharmacy Directory – Last Updated 11/08/2022
- H8634002
- Drug Formulary (PPO) – Last Updated 11/08/2022
- Find a Pharmacy
- Pharmacy Directory – Last Updated 11/08/2022
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- H1666012
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
- H8634002
- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
Prescription Drug Information
- H1666012
- Drug Formulary (PPO) – Last Updated 11/08/2022
- Find a Pharmacy
- Pharmacy Directory – Last Updated 11/08/2022
- H8634002
- Drug Formulary (PPO) – Last Updated 11/08/2022
- Find a Pharmacy
- Pharmacy Directory – Last Updated 11/08/2022
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List – Last Updated 09/30/2022
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
- H1666012
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Value (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – 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)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – 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)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex Access (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver Plus (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Select (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – 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)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – 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)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
East New Mexico - Formerly Amarillo Area
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Classic (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Premier (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Dental Value (HMO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – 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)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – 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)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Flex (PPO)SM
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (PPO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (PPO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Health Choice (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Saver Plus (PPO)SM
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO) – Last Updated 09/30/2022
- Optional Supplemental Benefits Enrollment Form (PPO) – Last Updated 09/30/2022
- Evidence of Coverage (PPO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO) – 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 (PPO)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
-
Blue Cross Medicare Advantage Select (HMO)SM
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – 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)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
General Plan Information- Annual Notice of Change (HMO) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (MAPD) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (HMO) – Last Updated 09/30/2022
- Evidence of Coverage (HMO) – Last Updated 09/30/2022
- Low Income Premium Subsidy (MAPD) – Last Updated 09/30/2022
- Plan Star Rating (HMO) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (HMO) – 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)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (MAPD) – Last Updated 09/30/2022
Medical Providers
Other
Statewide
-
Blue Cross Medicare Advantage Basic (HMO)SM
2022 Annual Notice of Change Basic (HMO) English | español
2022 Evidence of Coverage Basic (HMO) English | español
2022 Summary of Benefits Basic (HMO) English | español
2022 Enrollment Form (HMO) English | español
2022 Plan Star Rating (HMO) English | español
2022 Drug Formulary Basic (HMO) English | español
2022 Pharmacy Directory English | español
2022 Find a Doctor or Hospital English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List (MAPD) English | español
2022 Prescription Drug Coverage Determination Request Form (HMO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (HMO) English |español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
-
Blue Cross Medicare Advantage Select (HMO)SM
2022 Annual Notice of Change Select (HMO) English | español
2022 Evidence of Coverage Select (HMO) English | español
2022 Summary of Benefits Select (HMO) English | español
2022 Enrollment Form (HMO) English | español
2022 Plan Star Rating (HMO) English | español
2022 Drug Formulary (HMO) English | español
2022 Pharmacy Directory English | español
2022 Find a Doctor or Hospital English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List (MAPD) English | español
2022 Prescription Drug Coverage Determination Request Form (HMO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (HMO) English |español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
-
Blue Cross Medicare Advantage Classic (PPO)SM
2022 Evidence of Coverage Classic (PPO) English | español
2022 Summary of Benefits Classic (PPO) English | español
2022 Plan Star Rating (PPO) — Plan too new to be measured
2022 Enrollment Form (PPO) English | español
2022 Drug Formulary (PPO) English | español
2022 Pharmacy Directory English | español
2022 Find a Doctor or Hospital English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List (MAPD) English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English |español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
-
Blue Cross Medicare Advantage Flex (PPO)SM
2022 Evidence of Coverage Flex (PPO) English | español
2022 Summary of Benefits Flex (PPO) English | español
2022 Plan Star Rating (PPO) — Plan too new to be measured
2022 Enrollment Form (PPO) English | español
2022 Drug Formulary (PPO) English | español
2022 Pharmacy Directory English | español
2022 Find a Doctor or Hospital English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List (MAPD) English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English |español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
Albuquerque, Santa Fe and Surrounding Areas
-
Blue Cross Medicare Advantage Choice Plus (PPO)SM
2022 Annual Notice of Change Choice Plus (PPO) English | español
2022 Evidence of Coverage Choice Plus (PPO) English | español
2022 Summary of Benefits Choice Plus (PPO) English | español
2022 Enrollment Form (PPO) English | español
2022 Plan Star Rating (PPO) English | español
2022 Drug Formulary (PPO) English | español
2022 Pharmacy Directory English | español
2022 Find a Doctor or Hospital English | español
2022 Low Income Premium Subsidy (MAPD) English | español
2022 Prescription Drug Transition Policy (MAPD) English | español
2022 Personal Medication List (MAPD) English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English |español
2022 Online Coverage Redetermination Request Form
2022 Automated Premium Payment (ACH) Form (MAPD)
Last Updated: Nov. 17, 2022
Last Updated: 09302022
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