Plan Documents

Here you'll find a collection of our Massachusetts Medicare plan forms and plan information. Just click on the links below to download the forms you need.

Summary of Benefits

Evidence of Coverage (EOC)

Enrollment Applications

Medicare Advantage

Prescription Coverage

2013 Medicare Advantage Prescription Claim Form
2013 List of Medicare Advantage Network Pharmacies
2013 Medicare HMO Blue ValueRx/PlusRx Formulary
Updated 05/2013
2013 Medicare PPO Blue ValueRx/PlusRx Formulary
Updated 05/2013
2013 Medicare Advantage Group Formulary
Updated 05/2013
2013 Request for Medicare Prescription Drug Coverage Determination
2013 Medicare Advantage Prior Authorization Criteria
Updated 05/2013
2013 Medicare Advantage Step Therapy Criteria
Updated 05/2013
2013 Medicare Advantage Quality Care Dosing Guidelines
Updated 05/2013
2013 Request for Redetermination of Medicare Prescription Drug Denial
2013 Medicare Advantage Vaccine Claim Form

Fitness and Weight Loss Forms

Medex

Medex Subscriber Claim Form

Employer Group retiree coverage varies. Contact your employer's benefits administrator for specific information or, call Member Service at 1-800-200-4255 (TTY: 1-800-522-1254), as follows: from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week.

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