Forms and Documents

Find the forms and documents you need to manage your Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM offered by Blue Cross and Blue Shield of Illinois.

View these forms and documents in Spanish. If you have questions, please Contact Us.

• Annual Notice of Changes – Last Updated 02/15/2024
• Drug List (Formulary) – Last Updated 06/03/2024
• Member Handbook (includes document of coverage information) – Last Updated 06/03/2024
• Over-the-Counter (OTC) Benefit Catalog
• Over-the-Counter (OTC) Product Order Form
• Provider and Pharmacy Directory – Last Updated 06/03/2024
• Summary of Benefits – Last Updated 02/15/2024

• AllianceRx Walgreens Pharmacy Mail-Order Form
• Appointment of Representative – Last Updated 09/30/2023
• Critical Incident Form for Members – Last Updated 09/30/2023
• Express Scripts^® Pharmacy Mail-Order Form
• Frequently Asked Questions – Last Updated 09/30/2023
• HIPAA Notice of Privacy Practices – Last Updated 09/30/2023
• Power of Attorney
• Prescription Drug Transition Policy – Last Updated 09/30/2023
• Quality Improvement Form – Last Updated 02/20/2024

• Adult Wellness Guidelines
• Perinatal (Pregnancy) Wellness Guidelines

• Request for Medicare Prescription Drug Coverage Determination
• Request for Payment for Medicare Part D Drugs
• Request for Redetermination of Medicare Prescription Drug Denial

• Prior Authorization Criteria and Form
• Quantity Limits Exception Form
• Step Therapy Criteria and Form