Medicare plan documents

Plan overview and coverage

Choose a Medicare Advantage plan below (there are five plans). These documents explain covered services and include other helpful information about this plan.

Medicare Advantage Freedom Blue (medical only)

For information about your rights and responsibilities, please see Chapter 6 of the Evidence of Coverage Medicare Advantage document. For information about appeals and grievances, see Chapter 7.

• Summary of Benefits Medicare Advantage PPO - Freedom Blue
• Evidence of Coverage Medicare Advantage PPO - Freedom Blue
• Annual Notice of Changes Medicare Advantage PPO - Freedom Blue

Medicare Advantage (medical and Rx)

For information about other rights and responsibilities, please see Chapter 8 of the Evidence of Coverage Medicare Advantage document. For information about appeals and grievances, see Chapter 9. 

• Summary of Benefits PPO Metro Region - medical and Rx
• Evidence of Coverage Medicare Advantage PPO Metro Region - Core MAPD
• Evidence of Coverage Medicare Advantage PPO Metro Region - Comfort MAPD
• Evidence of Coverage Medicare Advantage PPO Metro Region - Choice MAPD
• Evidence of Coverage Medicare Advantage PPO Metro Region - Complete MAPD
• Annual Notice of Changes Medicare Advantage PPO Metro Region - Core
• Annual Notice of Changes Medicare Advantage PPO Metro Region - Comfort
• Annual Notice of Changes Medicare Advantage PPO Metro Region - Choice
• Annual Notice of Changes Medicare Advantage PPO Metro Region - Complete

Search for drugs

• Search online for drugs (Core and Comfort plans)
• Search online for drugs (Choice and Complete plans)
• Formulary (Drug List) Medicare Advantage PPO (Core and Comfort)
• Formulary (Drug List) Medicare Advantage PPO (Choice and Complete)
• Medicare Part B drugs that may be subject to step therapy
• Utilization management documents -- shows which drugs require special permission (known as a prior authorization) before they can be covered
• Request for prescription drug coverage exception

Doctors, pharmacies, and other networks

To get the most coverage from this plan, choose dentists, doctors, clinics, hospitals and pharmacies in the plan network.

Doctors

• Search online for doctors (providers)
• Provider Directory Medicare Advantage PPO - Metro & West Regions

Pharmacies

• Search online for pharmacies (Core and Comfort plans)
• Search online for pharmacies (Choice and Complete plans)
• Part D Pharmacy Directory – locations to fill prescription drugs covered under this Medicare Part D plan benefit.
• Part B Pharmacy Directory – locations to fill certain outpatient drugs that are covered under thid Medicare Part B plan benefit.

Dental

• Search online for Medicare dental providers
• Minnesota Medicare Dental Directory
• Medicare Advantage dental benefits overview
• Out-of-network dental reimbursement form

Other information and forms

• Medical claim form
• Medicare Advantage contact phone numbers
• Medicare transplant transportation and lodging reimbursement form
• Over-the-counter (OTC) benefit
• Post discharge meals
• Receiving care during a natural disaster or emergency
• SilverSneakers^® exercise and healthy aging program
• TruHearing^® hearing aid benefit
• Vision claim form

Enrollment

These forms are used to enroll in this plan. You can download them here, or order enrollment materials to be mailed to you.

• Enrollment form - Medicare Advantage Metro PPO
• Enrollment form - Medicare Advantage Freedom Blue (PPO)
• LIS premium summary - Medicare Advantage PPO Metro Region

Plan overview and coverage

Choose a Medicare Advantage plan below (there are five plans). These documents explain covered services and include other helpful information about this plan.

Medicare Advantage (medical only)

For information about your rights and responsibilities, please see Chapter 6 of the Evidence of Coverage Medicare Advantage document. For information about appeals and grievances, see Chapter 7.

• Summary of Benefits Medicare Advantage PPO - Freedom Blue
• Evidence of Coverage Medicare Advantage PPO - Freedom Blue
• Annual Notice of Changes Medicare Advantage PPO - Freedom Blue

Medicare Advantage (medical and Rx)

For information about other rights and responsibilities, please see Chapter 8 of the Evidence of Coverage Medicare Advantage document. For information about appeals and grievances, see Chapter 9.

• Summary of Benefits PPO West Region - MAPD
• Evidence of Coverage Medicare Advantage PPO West Region - Core
• Evidence of Coverage Medicare Advantage PPO West Region - Comfort
• Evidence of Coverage Medicare Advantage PPO West Region - Choice
• Evidence of Coverage Medicare Advantage PPO West Region - Complete
• Annual Notice of Changes Medicare Advantage PPO West Region - Core
• Annual Notice of Changes Medicare Advantage PPO West Region - Comfort
• Annual Notice of Changes Medicare Advantage PPO West Region - Choice
• Annual Notice of Changes Medicare Advantage PPO West Region - Complete

Search for drugs

• Search online for drugs (Core and Comfort plans)
• Search online for drugs (Choice and Complete plans)
• Formulary (Drug List) Medicare Advantage PPO (Core and Comfort)
• Formulary (Drug List) Medicare Advantage PPO (Choice and Complete)
• Medicare Part B drugs that may be subject to step therapy
• Utilization management documents - shows which drugs require special permission (known as a prior authorization) before they can be covered by this plan
• Request for prescription drug coverage exception

Doctors, pharmacies, and other networks

To get the most coverage from this plan, choose dentists, doctors, clinics, hospitals and pharmacies in the plan network.

Doctors

• Search online for doctors (providers)
• Provider Directory Medicare Advantage PPO - Metro & West Regions

Pharmacies

• Search online for pharmacies (Core and Comfort plans)
• Search online for pharmacies (Choice and Complete plans)
• Part D Pharmacy Directory – locations to fill prescription drugs covered under this Medicare Part D plan benefit.
• Part B Pharmacy Directory – locations to fill certain outpatient drugs that are covered under thid Medicare Part B plan benefit.

Dental

• Search online for Medicare dental providers
• Minnesota Medicare Dental Directory
• Medicare Advantage dental benefits overview
• Out-of-network dental reimbursement form

Other information and forms

• Medical claim form
• Medicare Advantage contact phone numbers
• Medicare transplant transportation and lodging reimbursement form
• Over-the-counter (OTC) benefit
• Post discharge meals
• Receiving care during a natural disaster or emergency
• SilverSneakers^® exercise and healthy aging program
• TruHearing^® hearing aid benefit
• Vision claim form

Enrollment

These forms are used to enroll in this plan. You can download them here, or order enrollment materials to be mailed to you.

• Enrollment form - Medicare Advantage PPO West Region
• Enrollment form - Medicare Advantage Freedom Blue (PPO)
• LIS Premium Summary - Medicare Advantage PPO West Region

Plan overview and coverage

Choose a Medicare Advantage plan below (there are four plans). These documents explain covered services and include other helpful information about this plan.

Medicare Advantage (medical only)

For information about your rights and responsibilities, please see Chapter 6 of the Evidence of Coverage Medicare Advantage document. For information about appeals and grievances, see Chapter 7.

• Summary of Benefits Medicare Advantage PPO - Freedom Blue
• Evidence of Coverage Medicare Advantage PPO - Freedom Blue
• Annual Notice of Changes Medicare Advantage PPO - Freedom Blue

Medicare Advantage (medical and Rx)

For information about other rights and responsibilities, please see Chapter 8 of the Evidence of Coverage Medicare Advantage document. For information about appeals and grievances, see Chapter 9.

• Summary of Benefits PPO Southern MN - MAPD
• Evidence of Coverage Medicare Advantage PPO Southern MN - Core MAPD
• Evidence of Coverage Medicare Advantage PPO Southern MN - Choice MAPD
• Evidence of Coverage Medicare Advantage PPO Southern MN - Complete MAPD
• Annual Notice of Changes Medicare Advantage PPO Southern MN - Core
• Annual Notice of Changes Medicare Advantage PPO Southern MN - Choice
• Annual Notice of Changes Medicare Advantage PPO Southern MN - Complete

Search for drugs

• Search online for drugs (Core plan)
• Search online for drugs (Choice and Complete plans)
• Formulary (Drug List) Medicare Advantage PPO (Core)
• Formulary (Drug List) Medicare Advantage PPO (Choice and Complete)
• Medicare Part B drugs that may be subject to step therapy
• Utilization management documents -- shows which drugs require special permission (known as a prior authorization) before they can be covered by this plan
• Request for prescription drug coverage exception

Doctors, pharmacies, and other networks

To get the most coverage from your plan, choose dentists, doctors, clinics, hospitals and pharmacies in the plan network.

Doctors

• Search online for doctors (providers)
• Provider Directory Medicare Advantage PPO Southern MN

Pharmacies

• Search online for pharmacies (Core plan)
• Search online for pharmacies (Choice and Complete plans)
• Part D Pharmacy Directory – locations to fill prescription drugs covered under this Medicare Part D plan benefit.
• Part B Pharmacy Directory – locations to fill certain outpatient drugs that are covered under thid Medicare Part B plan benefit.

Dental

• Search online for Medicare dental providers
• Minnesota Medicare Dental Directory
• Medicare Advantage dental benefits overview
• Out-of-network dental reimbursement form

Other information and forms

• Medical claim form
• Medicare Advantage contact phone numbers
• Medicare transplant transportation and lodging reimbursement form
• Over-the-counter (OTC) benefit
• Post discharge meals
• Receiving care during a natural disaster or emergency
• SilverSneakers^® exercise and healthy aging program
• TruHearing^® hearing aid benefit
• Vision claim form

Enrollment

These forms are used to enroll in this plan. You can download them here, or order enrollment materials to be mailed to you.

• Enrollment form - Medicare Advantage PPO Southern MN
• Enrollment form - Medicare Advantage Freedom Blue (PPO)
• LIS Premium Summary - Medicare Advantage PPO Southern MN

Plan overview and coverage

Choose a Platinum Blue plan below (there are three medical-only plans and three plans with medical and drug benefits). These documents explain covered services and include other helpful information about this plan.

Platinum Blue (medical only)

For information about your rights and responsibilities, please see Chapter 6 of your Evidence of Coverage Platinum Blue - document. For information about appeals and grievances, see Chapter 7.

• Summary of Benefits Platinum Blue
• Evidence of Coverage Platinum Blue - Core
• Evidence of Coverage Platinum Blue - Choice
• Evidence of Coverage Platinum Blue - Complete
• Annual Notice of Changes Platinum Blue - Core
• Annual Notice of Changes Platinum Blue - Choice
• Annual Notice of Changes Platinum Blue - Complete

Platinum Blue with Rx (medical and Rx)

For information about other rights and responsibilities, please see Chapter 8 of the Evidence of Coverage Platinum Blue - document. For information about appeals and grievances, see Chapter 9.

• Evidence of Coverage Platinum Blue - Core with Rx
• Evidence of Coverage Platinum Blue - Choice with Rx
• Evidence of Coverage Platinum Blue - Complete with Rx
• Annual Notice of Changes Platinum Blue - Core with Rx
• Annual Notice of Changes Platinum Blue - Choice with Rx
• Annual Notice of Changes Platinum Blue - Complete with Rx

Search for drugs

• Search online for drugs (Core plan)
• Search online for drugs (Choice and Complete plans)
• Formulary (Drug List) Platinum Blue with Rx (Core)
• Formulary (Drug List) Platinum Blue with Rx (Choice and Complete)
• Utilization management documents - shows which drugs require special permission (known as a prior authorization) before they can be covered by this plan
• Request for prescription drug coverage exception

Doctors, pharmacies, and other networks

To get the most coverage from this plan, choose dentists, doctors, clinics, hospitals and pharmacies in the plan network.

Doctors

• Search online for doctors (providers)
• Provider Directory Platinum Blue (Cost)

Pharmacies

• Search online for pharmacies (Core plan)
• Search online for pharmacies (Choice and Complete plans)
• Part D Pharmacy Directory – locations to fill prescription drugs covered under this Medicare Part D plan benefit.
• Part B Pharmacy Directory – locations to fill certain outpatient drugs that are covered under thid Medicare Part B plan benefit.

Dental

• Search online for Medicare dental providers
• Minnesota Medicare Dental Directory
• Medicare Platinum Blue dental benefits overview

Other information and forms

• Medical claim form
• Medicare transplant transportation and lodging reimbursement form
• Over-the-counter (OTC) benefit
• Platinum Blue contact phone numbers
• Receiving care during a natural disaster or emergency
• SilverSneakers^® exercise and healthy aging program
• TruHearing^® hearing aid benefit
• Vision claim form

Enrollment

These forms are used to enroll in this plan. You can download them here, or order enrollment materials to be mailed to you.

• Enrollment form - Platinum Blue
• LIS Premium Summary - Platinum Blue

Plan overview and coverage information

If you are enrolled in this plan, here are summaries of your coverage:

• Medicare Supplement Summary of Coverage and Disclosure

Doctors

To get the most coverage from this plan, choose doctors, hospitals and clinics in the plan network.

• Search online for doctors (providers)

Fitness program

• SilverSneakers^® exercise and healthy aging program

Other information and forms

• Medicare Supplement contact phone numbers
• Medicare deductibles, copayments and premium
• Medical claim form

Enrollment

These forms are used to enroll in this plan. You can download them here, or order enrollment materials to be mailed to you.

• Medicare supplement Enrollment form
• Medicare supplement Disenrollment form

Plan overview, pharmacies and coverage

If you are enrolled in this stand-alone Medicare prescription drug plan, visit:

• MedicareBlue Rx 2025

Doctors, pharmacies, and other networks

To get the most coverage from this plan, choose doctors, clinics, hospitals and pharmacies in the plan network.

Group Medicare Advantage PPO

Doctors

• Search online for doctors (providers)
• Provider Directory Group Medicare Advantage PPO

Pharmacies

• Search online for pharmacies
• Part D Pharmacy Directory – locations to fill prescription drugs covered under this Medicare Part D plan benefit.
• Part B Pharmacy Directory – locations to fill certain outpatient drugs that are covered under this Medicare Part B plan benefit.

Drugs

• Search online for drugs (All Others)
• Search online for drugs (Classic Rx 1 Plan Only)
• Formulary (Drug List) Group Medicare Advantage PPO (All Others)
• Formulary (Drug List) Group Medicare Advantage PPO (Classic Rx 1 Plan Only)
• Request for prescription drug coverage exception

Dental

• Search online for Medicare dental providers
• Minnesota Medicare Dental Directory
• Out-of-network dental reimbursement form for Classic Rx 1, Classic Rx2, Value Rx4, Select Rx 3, Premier Rx2 and Premier Rx 3 [COMING SOON]

Group Platinum Blue (Cost)

Doctors

• Search online for doctors (providers)
• Provider Directory Platinum Blue

Pharmacies

• Part B Pharmacy Directory – locations to fill certain outpatient drugs that are covered under this Medicare Part B plan benefit.

Other information and forms

• Medical claim form
• Medicare transplant transportation and lodging reimbursement form
• Over-the-counter (OTC) benefit
• Post discharge meals (Medicare Advantage plans only)
• Receiving care during a natural disaster or emergency
• SilverSneakers^® exercise and healthy aging program
• TruHearing^® hearing aid benefit
• Vision claim form

• Medicare complaint form
• Filing a complaint, appeal or grievance
• Medicare deductibles, copayments and premium
• Medicare formulary transition policy
• Best available evidence policy
• Appointment of representative
• Provider payment methods
• Privacy policy
• Multi-language interpreter services
• Notice of nondiscrimination
• Women's health & cancer rights
• Authorization for disclosure of health information form - English
• Authorization for disclosure of health information form - Hmong
• Authorization for disclosure of health information form - Spanish
• Power of attorney form

Rights and responsibilities upon disenrollment

When you leave or end your membership in Blue Cross Medicare plans it's called a disenrollment. A voluntary disenrollment is when you decide to leave the plan. You can do this only at certain times of the year, such as if you want to change to another plan during the annual enrollment period. An involuntary disenrollment is when the plan must end your membership. An example of this type of disenrollment is if you do not pay the plan's premiums.

If you are disenrolled for any reason, the plan will notify you of the date your membership will end and the reason for it ending. If you have questions about disenrollment, please call Customer Service at the back of your member ID card.