Medicare forms library

• Blue Medicare Advantage (HMO) Summary of Benefits (PDF)
• Blue Medicare Advantage (PPO) Summary of Benefits (PDF)
• Blue Medicare Freedom+ (PPO) Summary of Benefits (PDF)
• Healthy Blue + Medicare (HMO-POS) (D-SNP) Summary of Benefits (PDF)
• Blue Medicare Rx (PDP) Summary of Benefits (PDF)

2025

• Blue Medicare Advantage (HMO) Summary of Benefits (PDF)
• Blue Medicare Advantage (PPO) Summary of Benefits (PDF)
• Blue Medicare Freedom+ (PPO) Summary of Benefits (PDF)
• Healthy Blue + Medicare (HMO-POS) (D-SNP) Summary of Benefits (PDF)
• Blue Medicare Rx (PDP) Summary of Benefits (PDF)

• 2024 EOC Blue Medicare Choice (HMO) 026 (PDF)
• 2024 EOC Blue Medicare Essential (HMO) 027-001 (PDF)
• 2024 EOC Blue Medicare Essential (HMO) 027-002 (PDF)
• 2024 EOC Blue Medicare Enhanced (PPO) 003-001 (PDF)
• 2024 EOC Blue Medicare PPO Enhanced (PPO) 003-002 (PDF)
• 2024 EOC Blue Medicare PPO Freedom+ (PPO) 004 (PDF)
• 2024 EOC Blue Medicare Enhanced (HMO-POS) 024-001 (PDF)
• 2024 EOC Blue Medicare Enhanced (HMO-POS) 024-002 (PDF)
• 2024 EOC Blue Medicare Enhanced (HMO-POS) 024-003 (PDF)
• 2024 EOC Blue Medicare Medical Only (HMO-POS) 012 (PDF)
• 2024 EOC Blue Medicare Essential Plus (HMO-POS) 023-001 (PDF)
• 2024 EOC Blue Medicare Essential Plus (HMO-POS) 023-002 (PDF)
• 2024 EOC Blue Medicare Essential Plus HMO-POS 023-004 (PDF)
• 2024 EOC Blue Medicare Essential Plus HMO-POS 023-005 (PDF)
• 2024 EOC Blue Medicare Enhanced (PDP) 004 (PDF)
• 2024 EOC Blue Medicare Standard (PDP) 002 (PDF)
• 2024 Healthy Blue + Medicare (HMO D-SNP) EOC (PDF)

2025

• 2025 EOC Blue Medicare PPO Enhanced (PPO) 003-001 (PDF)
• 2025 EOC Blue Medicare PPO Enhanced (PPO) 003-002 (PDF)
• 2025 EOC Blue Medicare Freedom Plus (PPO) 004 (PDF)
• 2025 EOC Blue Medicare Medical Only (HMO-POS) 012 (PDF)
• 2025 EOC Blue Medicare Essential Plus (HMO-POS) 023-001 (PDF)
• 2025 EOC Blue Medicare Essential Plus (HMO-POS) 023-002 (PDF)
• 2025 EOC Blue Medicare Essential Plus (HMO-POS) 023-004 (PDF)
• 2025 EOC Blue Medicare Essential Plus (HMO-POS) 023-005 (PDF)
• 2025 EOC Blue Medicare Enhanced (HMO-POS) 024-001 (PDF)
• 2025 EOC Blue Medicare Enhanced (HMO-POS) 024-002 (PDF)
• 2025 EOC Blue Medicare Enhanced (HMO-POS) 024-003 (PDF)
• 2025 EOC Blue Medicare Choice (HMO) 026 (PDF)
• 2025 EOC Blue Medicare Essential (HMO) 027-001 (PDF)
• 2025 EOC Blue Medicare Essential (HMO) 027-002 (PDF)
• 2025 EOC Blue Medicare Rx Standard (PDP) 002 (PDF)
• 2025 EOC Blue Medicare Rx Enhanced (PDP) 004 (PDF)
• 2025 EOC Healthy Blue Medicare (HMO-POS) (D-SNP) (PDF)

• 2024 ANOC Blue Medicare Choice (HMO) (PDF)
• 2024 ANOC Blue Medicare Enhanced (HMO-POS) 024-001 (PDF)
• 2024 ANOC Blue Medicare Enhanced (HMO-POS) 024-002 (PDF)
• 2024 ANOC Blue Medicare Enhanced (HMO-POS) 024-003 (PDF)
• 2024 ANOC Blue Medicare Enhanced (HMO-POS) 024-003 to 002 (PDF)
• 2024 ANOC Blue Medicare Enhanced HMO 024-003 to 001 (PDF)
• 2024 ANOC Blue Medicare Medical Only (HMO-POS) (PDF)
• 2024 ANOC Blue Medicare Essential (HMO) H3449-027-001 (PDF)
• 2024 ANOC Blue Medicare Essential (HMO) H3449-027-002 (PDF)
• 2024 ANOC Blue Medicare Essential (HMO) H3449-027-002 to 001 (PDF)
• 2024 ANOC Blue Medicare Essential Plus (HMO-POS) H3449-023-001 (PDF)
• 2024 ANOC Blue Medicare Essential Plus (HMO-POS) H3449-023-002 (PDF)
• 2024 ANOC Blue Medicare Essential Plus (HMO-POS) H3449-023-004 (PDF)
• 2024 ANOC Essential Plus (HMO-POS) H3449-023-005 (PDF)
• 2024 ANOC Essential Plus (HMO-POS) H3449-023-004 to 002 (PDF)
• 2024 ANOC Essential Plus (HMO-POS) H3449-023-004 to 001 (PDF)
• 2024 ANOC Essential Plus (HMO-POS) H3449-023-005 to 001 (PDF)
• 2024 ANOC Essential Plus (HMO-POS) H3449-023-005 to 002 (PDF)
• 2024 ANOC Enhanced (PDP) S5540 004 (PDF)
• 2024 ANOC Standard (PDP) S5540 002 (PDF)
• 2024 ANOC PPO Enhanced (PPO) 003-001 (PDF)
• 2024 ANOC PPO Enhanced (PPO) 003-002 (PDF)
• 2024 ANOC PPO Enhanced (PPO) 003-002 to 001 (PDF)
• 2024 ANOC Healthy Blue + Medicare (HMO D-SNP) (PDF)
• 2024 ANOC Freedom+ (PPO) 004 (PDF)

2025

• 2025 ANOC Blue Medicare Choice (HMO) 026-000 (PDF)
• 2025 ANOC Blue Medicare Enhanced (HMO-POS) 024-001 (PDF)
• 2025 ANOC Blue Medicare Enhanced (HMO-POS) 024-002 (PDF)
• 2025 ANOC Blue Medicare Enhanced (HMO-POS) 024-003 (PDF)
• 2025 ANOC Blue Medicare Essential (HMO) 027-001 (PDF)
• 2025 ANOC Blue Medicare Essential (HMO) 027-002 (PDF)
• 2025 ANOC Blue Medicare Essential Plus (HMO-POS) 023-001 (PDF)
• 2025 ANOC Blue Medicare Essential Plus (HMO-POS) 023-001 to 004 (PDF)
• 2025 ANOC Blue Medicare Essential Plus (HMO-POS) 023-002 (PDF)
• 2025 ANOC Blue Medicare Essential Plus (HMO-POS) 023-002 to 005 (PDF)
• 2025 ANOC Blue Medicare Essential Plus (HMO-POS) 023-004 (PDF)
• 2025 ANOC Blue Medicare Essential Plus (HMO-POS) 023-005 (PDF)
• 2025 ANOC Blue Medicare Medical Only (HMO-POS) 012 (PDF)
• 2025 ANOC Blue Medicare PPO Enhanced (PPO) 003-001 (PDF)
• 2025 ANOC Blue Medicare PPO Enhanced (PPO) 003-002 (PDF)
• 2025 ANOC Blue Medicare PPO Enhanced (PPO) 003-002 to 001 (PDF)
• 2025 ANOC Blue Medicare PPO Freedom Plus (PPO) 004 (PDF)
• 2025 ANOC Blue Medicare Rx Enhanced (PDP) 004 (PDF)
• 2025 ANOC Blue Medicare Rx Standard (PDP) 002 (PDF)
• 2025 ANOC Healthy Blue Medicare (HMO-POS) (D-SNP) (PDF)

• Liberty Dental Comprehensive Plan (PDF)
• Liberty Dental Preventive Plus Plan (PDF)
• Liberty Dental Codes (PDF)

The list of drugs covered on each plan, along with any restrictions for those drugs, can be found in the formulary.

2024

• Blue Medicare Choice (HMO) (PDF)
• Blue Medicare Enhanced (HMO-POS) (PDF)
• Blue Medicare Essential (HMO) (PDF)
• Blue Medicare Essential Plus (HMO-POS) (PDF)
• Blue Medicare PPO Enhanced (PPO) (PDF)
• Blue Medicare Rx Enhanced (PDP) (PDF)
• Blue Medicare Rx Standard (PDP) (PDF)
• Blue Medicare HMO EGWP MAPD (PDF)
• Blue Medicare HMO EGWP MAPD (plans with deductible) (PDF)
• Blue Medicare PPO EGWP MAPD (PDF)
• Blue Medicare Rx EGWP HCE (PDF)
• Blue Medicare PPO EGWP Complete (PDF)
• Blue Medicare Rx EGWP Complete (PDF)
• Healthy Blue + Medicare (HMO D-SNP) (PDF)

2025

• Blue Medicare Choice (HMO) (PDF)
• Blue Medicare Enhanced (HMO-POS) (PDF)
• Blue Medicare Essential (HMO) (PDF)
• Blue Medicare Essential Plus (HMO-POS) (PDF)
• Blue Medicare PPO Enhanced (PPO) (PDF)
• Blue Medicare Rx Enhanced (PDP) (PDF)
• Blue Medicare Rx Standard (PDP) (PDF)
• Healthy Blue + Medicare (HMO D-SNP) (PDF)

• 2024 Blue Medicare HMO, PPO, and Rx (PDF)
  
• 2024 Healthy Blue + Medicare (PDF)

2025

• 2025 Blue Medicare HMO, PPO, and Rx (PDF)
• 2025 Healthy Blue + Medicare (PDF)

• 2024 Star Ratings Blue Medicare (HMO) (PDF)
• 2024 Star Ratings Blue Medicare (PPO) (PDF)
• 2024 Star Ratings Blue Medicare Rx (PDP) (PDF)
• 2024 Star Ratings Healthy Blue Medicare (HMO-POS) (D-SNP) (PDF)
• 2024 Star Ratings Healthy Blue Medicare (HMO-POS) (D-SNP) (Spanish) (PDF)

• 2025 Star Ratings Blue Medicare (HMO) (PDF)
• 2025 Star Ratings Blue Medicare (PPO) (PDF)
• 2025 Star Ratings Blue Medicare Rx (PDP) (PDF)
• 2025 Star Ratings Healthy Blue Medicare (HMO-POS) (D-SNP) (PDF)
• 2025 Star Ratings Healthy Blue Medicare (HMO-POS) (D-SNP) (Spanish) (PDF)

2025 Medicare and You Handbook (PDF)

• 2025 Blue Medicare Advantage HMO Enrollment Form (PDF)
• 2025 Blue Medicare Advantage PPO Enrollment Form (PDF)
• 2025 Blue Medicare Advantage Freedom+ PPO Enrollment Form (PDF)
• 2025 Blue Medicare Rx PDP Enrollment Form (PDF)
  
• 2025 Healthy Blue Medicare HMO-POS D-SNP Enrollment Form (PDF)

• 2024 Blue Medicare HMO Change Form (PDF)
  
• 2024 Blue Medicare PPO Change Form (PDF)

• 2025 Blue Medicare HMO Change Form (PDF)
  
• 2025 Blue Medicare PPO Change Form (PDF)
• 2025 Blue Medicare Rx PDP Change Form (PDF)

• Medicare Medical Claim Form (PDF) Or, submit your Medical Claim online through your Blue Connect℠ member portal.
• Medicare Prescription Drug Claim Form (PDF)
• Liberty Dental Claim Form (PDF)
• Medicare Vaccine Claim Form (PDF)

• Authorization for Automatic Bank Draft Form (PDF)

• Appointment of Representative (AOR) Form (PDF)

• PHI Authorization Request Form (PDF) Or, submit your request through your Blue Connect℠ member portal.

• Reducing Your Risk for Type 2 Diabetes - MDPP information and referral form (PDF)

• Medicare Part B vs Part D Fax Form (PDF)
• Part B Step Therapy Drug List NC (PDF)

• Compounded Drugs Request Fax Form (PDF)
• Coverage Determination Request Form (PDF)
• Hospice Information for Medicare Part D Plans (PDF)

Members with Blue Medicare Choice℠, Blue Medicare Essential℠, Blue Medicare Essential Plus℠, Blue Medicare Enhanced℠, and Blue Medicare PPO Enhanced℠ can take advantage of $0 copay drugs at preferred retail pharmacies and Express Scripts and Walgreens Mail Service mail-order pharmacies, or a low copay at standard pharmacies.

The Formulary Tier 6 Select Care drug list below includes a wide range of commonly prescribed generic drugs used for high blood pressure, high cholesterol, and diabetes. Talk with your doctor to determine if a Formulary Tier 6 Select Care drug is appropriate to treat your condition so that you get the best value from your pharmacy benefits.

2024 Formulary Tier 6 Select Care Drugs (PDF)