Medicare forms library

2026

• 2026 Summary of Benefits Blue Medicare Advantage (HMO) (PDF)
• 2026 Summary of Benefits Blue Medicare Advantage (PPO) (PDF)
• 2026 Summary of Benefits Blue Medicare Freedom+ (PPO) (PDF)
• 2026 Summary of Benefits Healthy Blue + Medicare (HMO-POS D-SNP) (PDF)
• 2026 Summary of Benefits Blue Medicare Rx (PDP) (PDF)

2027

• 2027 Summary of Benefits Blue Medicare Advantage (HMO) (PDF)
• 2027 Summary of Benefits Blue Medicare Advantage HMO Enhanced (HMO) (PDF)
• 2027 Summary of Benefits Blue Medicare Advantage (PPO) (PDF)
• 2027 Summary of Benefits Blue Medicare Freedom+ (PPO) (PDF)
• 2027 Summary of Benefits Healthy Blue + Medicare (HMO-POS D-SNP) (PDF)
• 2027 Summary of Benefits Blue Medicare Rx (PDP) (PDF)

2026

• 2026 EOC Blue Medicare PPO Enhanced (PPO) 003-001 (PDF)
• 2026 EOC Blue Medicare PPO Enhanced (PPO) 003-002 (PDF)
• 2026 EOC Blue Medicare Freedom Plus (PPO) 004 (PDF)
• 2026 EOC Blue Medicare Medical Only (HMO-POS) 012 (PDF)
• 2026 EOC Blue Medicare Essential Plus (HMO-POS) 023-001 (PDF)
• 2026 EOC Blue Medicare Essential Plus (HMO-POS) 023-002 (PDF)
• 2026 EOC Blue Medicare Essential Plus (HMO-POS) 023-004 (PDF)
• 2026 EOC Blue Medicare Essential Plus (HMO-POS) 023-005 (PDF)
• 2026 EOC Blue Medicare Enhanced (HMO-POS) 024-001 (PDF)
• 2026 EOC Blue Medicare Enhanced (HMO-POS) 024-002 (PDF)
• 2026 EOC Blue Medicare Enhanced (HMO-POS) 024-003 (PDF)
• 2026 EOC Blue Medicare Choice (HMO) 026 (PDF)
• 2026 EOC Blue Medicare Essential (HMO) 027-001 (PDF)
• 2026 EOC Blue Medicare Essential (HMO) 027-002 (PDF)
• 2026 EOC Blue Medicare Rx Enhanced (PDP) 004 (PDF)
• 2026 EOC Blue Medicare Rx Standard (PDP) 002 (PDF)
• 2026 EOC Healthy Blue + Medicare (HMO-POS D-SNP) 001 (PDF)

2027

• 2027 EOC Blue Medicare Freedom Plus (PPO) 004 (PDF)
• 2027 EOC Blue Medicare Medical Only (HMO-POS) 012 (PDF)
• 2027 EOC Healthy Blue + Medicare (HMO-POS D-SNP) 001 (PDF)
• 2027 EOC Blue Medicare Rx Enhanced (PDP) 004 (PDF)
• 2027 EOC Blue Medicare Rx Standard (PDP) 002 (PDF)
• 2027 EOC Blue Medicare PPO Enhanced (PPO) 003 (PDF)
• 2027 EOC Blue Medicare Essential Plus (HMO-POS) 023 (PDF)
• 2027 EOC Blue Medicare Enhanced (HMO-POS) 024 (PDF)
• 2027 EOC Blue Medicare Essential (HMO) 027 (PDF)

2026

• 2026 ANOC Blue Medicare PPO Enhanced (PPO) 003-001 to 002 (PDF)
• 2026 ANOC Blue Medicare PPO Enhanced (PPO) 003-001 (PDF)
• 2026 ANOC Blue Medicare PPO Enhanced (PPO) 003-002 to 001 (PDF)
• 2026 ANOC Blue Medicare PPO Enhanced (PPO) 003-002 (PDF)
• 2026 ANOC Blue Medicare PPO Freedom Plus (PPO) 004 (PDF)
• 2026 ANOC Blue Medicare Medical Only (HMO-POS) 012 (PDF)
• 2026 ANOC Blue Medicare Essential Plus (HMO-POS) 023-001 to 002 (PDF)
• 2026 ANOC Blue Medicare Essential Plus (HMO-POS) 023-001 (PDF)
• 2026 ANOC Blue Medicare Essential Plus (HMO-POS) 023-002 to 001 (PDF)
• 2026 ANOC Blue Medicare Essential Plus (HMO-POS) 023-002 to 004 (PDF)
• 2026 ANOC Blue Medicare Essential Plus (HMO-POS) 023-002 (PDF)
• 2026 ANOC Blue Medicare Essential Plus (HMO-POS) 023-004 to 005 (PDF)
• 2026 ANOC Blue Medicare Essential Plus (HMO-POS) 023-004 (PDF)
• 2026 ANOC Blue Medicare Essential Plus (HMO-POS) 023-005 (PDF)
• 2026 ANOC Blue Medicare Enhanced (HMO-POS) 024-001 to 002 (PDF)
• 2026 ANOC Blue Medicare Enhanced (HMO-POS) 024-001 to 003 (PDF)
• 2026 ANOC Blue Medicare Enhanced (HMO-POS) 024-001 (PDF)
• 2026 ANOC Blue Medicare Enhanced (HMO-POS) 024-002 to 001 (PDF)
• 2026 ANOC Blue Medicare Enhanced (HMO-POS) 024-002 to 003 (PDF)
• 2026 ANOC Blue Medicare Enhanced (HMO-POS) 024-002 (PDF)
• 2026 ANOC Blue Medicare Enhanced (HMO-POS) 024-003 (PDF)
• 2026 ANOC Blue Medicare Choice (HMO) 026-000 (PDF)
• 2026 ANOC Blue Medicare Essential (HMO) 027-001 to 002 (PDF)
• 2026 ANOC Blue Medicare Essential (HMO) 027-001 (PDF)
• 2026 ANOC Blue Medicare Essential (HMO) 027-002 to 001 (PDF)
• 2026 ANOC Blue Medicare Essential (HMO) 027-002 (PDF)
• 2026 ANOC Blue Medicare Rx Standard (PDP) 002 (PDF)
• 2026 ANOC Blue Medicare Rx Enhanced (PDP) 004 (PDF)
• 2026 ANOC Healthy Blue + Medicare (HMO-POS D-SNP) 001 (PDF)

2027

• 2027 ANOC Blue Medicare PPO Enhanced (PPO) 003-001 (PDF)
• 2027 ANOC Blue Medicare PPO Enhanced (PPO) 003-002 (PDF)
• 2027 ANOC Blue Medicare PPO Freedom Plus (PPO) 004 (PDF)
• 2027 ANOC Blue Medicare Medical Only (HMO-POS) 012 (PDF)
• 2027 ANOC Blue Medicare Essential Plus (HMO-POS) 023-001 (PDF)
• 2027 ANOC Blue Medicare Essential Plus (HMO-POS) 023-002 (PDF)
• 2027 ANOC Blue Medicare Essential Plus (HMO-POS) 023-004 (PDF)
• 2027 ANOC Blue Medicare Essential Plus (HMO-POS) 023-005 (PDF)
• 2027 ANOC Blue Medicare Enhanced (HMO-POS) 024-001 (PDF)
• 2027 ANOC Blue Medicare Enhanced (HMO-POS) 024-002 (PDF)
• 2027 ANOC Blue Medicare Enhanced (HMO-POS) 024-003 (PDF)
• 2027 ANOC Blue Medicare Essential (HMO) 027-001 (PDF)
• 2027 ANOC Blue Medicare Essential (HMO) 027-002 (PDF)
• 2027 ANOC Healthy Blue + Medicare (HMO-POS D-SNP) 001 (PDF)
• 2027 ANOC Blue Medicare Rx Standard (PDP) 002 (PDF)
• 2027 ANOC Blue Medicare Rx Enhanced (PDP) 004 (PDF)
• 2027 ANOC Blue Medicare Essential Plus (HMO-POS) H3777-002 to H3449-023-001 (PDF)
• 2027 ANOC Blue Medicare Essential Plus (HMO-POS) H3777-002 to H3449-023-002 (PDF)
• 2027 ANOC Blue Medicare Essential Plus (HMO-POS) H3777-002 to H3449-023-004 (PDF)
• 2027 ANOC Blue Medicare Essential Plus (HMO-POS) H3777-002 to H3449-023-005 (PDF)

2026

• 2026 Liberty Dental Comprehensive Plan for D-SNP Benefit Highlights (PDF)
• 2026 Liberty Dental Preventive Plus Plan Benefit Highlights (PDF)
• 2026 Liberty Dental Comprehensive $1,500 maximum Plan Benefit Highlights (PDF)
• 2026 Liberty Dental Comprehensive $2,000 maximum Plan Benefit Highlights (PDF)
• 2026 Liberty Dental Comprehensive Plan for D-SNP procedure codes (PDF)
• 2026 Liberty Dental Preventive Plus Plan procedure codes (PDF)
• 2026 Liberty Dental Comprehensive Plan procedure codes (PDF)

2027

• 2027 Liberty Dental Comprehensive Plan for D-SNP procedure codes (PDF)
• 2027 Liberty Dental Preventive Plus Plan procedure codes (PDF)
• 2027 Liberty Dental Comprehensive $1,500 maximum Plan procedure codes (PDF)
• 2027 Liberty Dental Comprehensive $2,000 maximum Plan procedure codes (PDF)

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

• Log in to your member portal and select "Find a Medication" to view estimated costs, drug limitations or requirements, and other covered medications.

2026

• 2026 Formulary Blue Medicare Choice (HMO) (PDF)
• 2026 Formulary Blue Medicare Enhanced (HMO-POS) (PDF)
• 2026 Formulary Blue Medicare Essential (HMO) (PDF)
• 2026 Formulary Blue Medicare Essential Plus (HMO-POS) (PDF)
• 2026 Formulary Blue Medicare PPO Enhanced (PPO) (PDF)
• 2026 Formulary Blue Medicare Rx Enhanced (PDP) (PDF)
• 2026 Formulary Blue Medicare Rx Standard (PDP) (PDF)
• 2026 Formulary Blue Medicare (HMO) EGWP MAPD (PDF)
• 2026 Formulary Blue Medicare (HMO) EGWP MAPD (plans with deductible) (PDF)
• 2026 Formulary Blue Medicare (PPO) EGWP MAPD (PDF)
• 2026 Formulary Blue Medicare (PPO) EGWP Complete (PDF)
• 2026 Formulary Blue Medicare Rx EGWP (PDP) Complete (PDF)
• 2026 Formulary Healthy Blue + Medicare (HMO-POS D-SNP) (PDF)

2027

• 2027 Formulary Healthy Blue + Medicare (HMO-POS D-SNP) (PDF)
• 2027 Formulary Blue Medicare Enhanced (HMO-POS) (PDF)
• 2027 Formulary Blue Medicare Essential (HMO) (PDF)
• 2027 Formulary Blue Medicare Essential Plus (HMO-POS) (PDF)
• 2027 Formulary Blue Medicare PPO Enhanced (PPO) (PDF)
• 2027 Formulary Blue Medicare Rx Enhanced (PDP) (PDF)
• 2027 Formulary Blue Medicare Rx Standard (PDP) (PDF)

Learn more about how to get your prescriptions by mail.

The Pharmacy Directory lists our network pharmacies. To locate a pharmacy in your area, log in to your member portal or select your plan's Pharmacy Directory PDF.

2026

• 2026 Pharmacy Directory Blue Medicare (HMO), (PPO), and Rx (PDP) (PDF)
• 2026 Pharmacy Directory Healthy Blue + Medicare (HMO-POS D-SNP) (PDF)

2027

• 2027 Pharmacy Directory Blue Medicare (HMO), (PPO), and Rx (PDP) (PDF)
• 2027 Pharmacy Directory Healthy Blue + Medicare (HMO-POS D-SNP) (PDF)

2026 Star Ratings Blue Medicare Rx (PDP) (PDF)

2026 Star Ratings Healthy Blue + Medicare (HMO-POS D-SNP) (PDF)

2026 Star Ratings Blue Medicare (HMO) (PDF)

2026 Star Ratings Blue Medicare (PPO) (PDF)

2026

• 2026 Individual Enrollment Form Medicare Advantage (HMO) (PDF) Prospective members can use this form to enroll in Blue Medicare Advantage HMO plans.
• 2026 Individual Enrollment Form Medicare Advantage (PPO) (PDF) Prospective members can use this form to enroll in Blue Medicare Advantage PPO plans.
• 2026 Individual Enrollment Form Medicare Advantage Blue Medicare Freedom+ (PPO) (PDF) Prospective members can use this form to enroll in Blue Medicare Advantage Freedom+ PPO plan.
• 2026 Individual Enrollment Form Medicare Rx (PDP) (PDF) Prospective members can use this form to enroll in Blue Medicare Rx Standard and Enhanced PDP plans.
• 2026 Individual Enrollment Form Healthy Blue + Medicare (HMO-POS D-SNP) (PDF) Prospective members can use this form to enroll in Healthy Blue + Medicare HMO-POS D-SNP.

2027

• 2027 Individual Enrollment Form Medicare Advantage (HMO) (PDF) Prospective members can use this form to enroll in Blue Medicare Advantage Medical Only HMO-POS, Essential HMO, or Essential Plus HMO-POS plans.
• 2027 Individual Enrollment Form Medicare Advantage Enhanced (HMO-POS) (PDF) Prospective members can use this form to enroll in Blue Medicare Advantage Enhanced HMO-POS plans.
• 2027 Individual Enrollment Form Medicare Advantage (PPO) (PDF) Prospective members can use this form to enroll in Blue Medicare Advantage PPO Enhanced plans.
• 2027 Individual Enrollment Form Medicare Advantage Blue Medicare Freedom+ (PPO) (PDF) Prospective members can use this form to enroll in Blue Medicare Advantage Freedom+ PPO plan.
• 2027 Individual Enrollment Form Medicare Rx (PDP) (PDF) Prospective members can use this form to enroll in Blue Medicare Rx Standard and Enhanced PDP plans.
• 2027 Individual Enrollment Form Healthy Blue + Medicare (HMO-POS D-SNP) (PDF) Prospective members can use this form to enroll in Healthy Blue + Medicare HMO-POS D-SNP.

2026

• 2026 Change Form Medicare Advantage (PPO) (PDF)
• 2026 Change Form Medicare Advantage (HMO) (PDF)
• 2026 Change Form Blue Medicare Rx (PDP) (PDF)

2027

• 2027 Change Form Medicare Advantage (HMO) (PDF)
• 2027 Change Form Blue Medicare Rx (PDP) (PDF)

Medicare Medical Claim Form (PDF) Or, log in to your member portal to submit your Medical Claim online.

Medicare Prescription Drug Claim Form (PDF)

Liberty Dental Claim Form (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 copays for Select Care drugs at preferred retail and mail order pharmacies, or with a low copay at standard pharmacies.

Learn more about your pharmacy network.

The Formulary Tier 6 Select Care drug list 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 you get the best value from your pharmacy benefits.

2026 Formulary Tier 6 (Select Care Drugs) (PDF)