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
Prescription Drug Information
- Drug Formulary (HMO SNP) – 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 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 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 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
Prescription Drug Information
- Drug Formulary (PPO SNP) – 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 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 09/30/2022
- 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 09/30/2022
- 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
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Blue Cross Medicare Advantage Dual Care Plus (HMO SNP)SM
2022 Annual Notice of Change Dual Care Plus (HMO SNP) English | español
2022 Evidence of Coverage Dual Care Plus (HMO SNP) English | español
2022 Summary of Benefits Dual Care Plus (DSNP) English | español
2022 Enrollment Form Dual Care Plus (HMO SNP) English | español
2022 Plan Star Rating (HMO SNP) English | español
2022 Drug Formulary (HMO SNP) English | español
2020 Program Summary Results English | español
2022 Pharmacy Directory English | español
2022 Find a Doctor or Hospital English | español
2022 Low Income Premium Subsidy (HMO SNP) English | español
2022 Prescription Drug Transition Policy (HMO SNP) English | español
2022 Personal Medication List (HMO SNP) English | español
2022 Prescription Drug Coverage Determination Request Form (HMO SNP) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (HMO SNP) English | español
2022 Online Coverage Determination Request Form
2022 Automated Premium Payment (ACH) Form (DSNP)
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Blue Cross Medicare Advantage Dual Care Plus Preferred (PPO SNP)SM
2022 Evidence of Coverage Dual Care Preferred (PPO SNP) English | español
2022 Summary of Benefits Dual Care Preferred (PPO SNP) English | español
2022 Plan Star Rating (PPO-POS) — Plan too new to be measured
2022 Enrollment Form Dual Care Preferred (PPO SNP) English | español
2022 Drug Formulary (PPO SNP) English | español
2022 Pharmacy Directory English | español
2022 Find a Doctor or Hospital English | español
2022 Low Income Premium Subsidy (PPO SNP) English | español
2022 Prescription Drug Transition Policy (PPO SNP) English | español
2022 Personal Medication List (PPO SNP) English | español
2022 Prescription Drug Coverage Determination Request Form (PPO SNP) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO SNP) English | español
2022 Online Coverage Determination Request Form
2022 Automated Premium Payment (ACH) Form (DSNP)
Last Updated: Nov. 21, 2022
Last Updated: 09302022
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