Medicare Advantage Dual Care Plan Documents
Find the documents you need to help you manage your Medicare Advantage Dual Care 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.
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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 11/15/2022
- 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
- Medicare Individual DSNP Summary - Last Updated 01/23/2023
- Summary of Benefits 2021 - Last Updated 03/13/2023
Prescription Drug Information
- Drug Formulary (HMO SNP) – Last Updated 03/01/2023
- 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 03/01/2023
- 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 11/15/2022
- 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 03/01/2023
- 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 03/01/2023
- 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 Preferred (PPO SNP)SM
General Plan Information- Annual Notice of Change (PPO SNP) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (PPO SNP) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO SNP) – Last Updated 09/30/2022
- Evidence of Coverage (PPO SNP) – Last Updated 11/15/2022
- Low Income Premium Subsidy (PPO SNP) – Last Updated 09/30/2022
- Plan Star Rating (PPO SNP) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
- Spanish Medicare Individual DSNP Summary - Last Updated 01/23/2023
Prescription Drug Information
- Drug Formulary (PPO SNP) – Last Updated 03/01/2023
- 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 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO SNP)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (PPO SNP) – Last Updated 09/30/2022
Other
General Plan Information- Annual Notice of Change (PPO SNP) – Last Updated 09/30/2022
- Automated Premium Payment (ACH) Form (PPO SNP) – Last Updated 09/30/2022
- CMS Appointment of Representative Form – Last Updated 09/30/2022
- Enrollment Form (PPO SNP) – Last Updated 09/30/2022
- Evidence of Coverage (PPO SNP) – Last Updated 11/15/2022
- Low Income Premium Subsidy (PPO SNP) – Last Updated 09/30/2022
- Plan Star Rating (PPO SNP) – Last Updated 10/27/2022
- Summary of Benefits – Last Updated 09/30/2022
Prescription Drug Information
- Drug Formulary (PPO SNP) – Last Updated 03/01/2023
- 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 03/01/2023
- Prescription Drug Coverage Determination Request Form (PPO SNP)
- Prescription Drug Coverage Redetermination Request Form
- Prescription Drug Transition Policy (PPO SNP) – Last Updated 09/30/2022
Other
Last Updated: March 13, 2023
Last Updated: 09302022
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