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.
Statewide
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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)
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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 Optional Supplemental Benefits Enrollment Form (PPO) English | español
Current members should download, complete and submit this form to opt in for buy-up options.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)
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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 Optional Supplemental Benefits Enrollment Form (PPO) English | español
Current members should download, complete and submit this form to opt in for buy-up options.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)
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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
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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 Optional Supplemental Benefits Enrollment Form (PPO) English | español
Current members should download, complete and submit this form to opt in for buy-up options.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: 09302021
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