Medicare Advantage
Forms and documents

Annual notice of changes

These important documents help prepare you for Medicare's Annual Open Enrollment (AEP) by providing details about new and changed benefits.

• 2025 Annual Notice of Changes for Blue Medicare Advantage (PPO) for Chase, Coffey, Douglas, Franklin, Geary, Jackson, Jefferson, Leavenworth, Linn, Lyon, Miami, Morris, Osage, Pottawatomie, Riley, Shawnee and Wabaunsee counties (PDF)
  (document 37-034 06/24)
• 2025 Annual Notice of Changes for Blue Medicare Advantage (PPO) for Butler, Cowley, Dickinson, Harvey, Kingman, Marion, McPherson, Reno, Sedgwick and Sumner counties (PDF)
  (document 37-036 06/24)
• 2025 Annual Notice of Changes for Blue Medicare Advantage Choice (PPO) (PDF)
  (document 37-035 06/24)
  Available in these counties: Allen, Anderson, Bourbon, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Douglas, Elk, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Neosho, Osage, Pottawatomie, Reno, Riley, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.
• 2025 Annual Notice of Changes for Blue Medicare Advantage Comprehensive (PPO) (PDF)
  (document 37-037 06/24)
  Available in these counties: Allen, Anderson, Bourbon, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Douglas, Elk, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Neosho, Osage, Pottawatomie, Reno, Riley, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.
• 2025 Annual Notice of Changes for Blue Medicare Advantage Freedom (PPO) (PDF)
  (document 37-066 03/23)
  Available in these counties: Allen, Anderson, Bourbon, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Douglas, Elk, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Neosho, Osage, Pottawatomie, Reno, Riley, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.
• 2026 Annual Notice of Changes for Blue Medicare Advantage (PPO) for Chase, Coffey, Douglas, Franklin, Geary, Jackson, Jefferson, Leavenworth, Linn, Lyon, Miami, Morris, Osage, Pottawatomie, Riley, Shawnee and Wabaunsee counties (PDF, 9.1mb)
  (document 37-034 06/25)
• 2026 Annual Notice of Changes for Blue Medicare Advantage (PPO) for Butler, Cowley, Dickinson, Harvey, Kingman, Marion, McPherson, Reno, Sedgwick and Sumner counties (PDF, 9.1mb)
  (document 37-036 06/25)
• 2026 Annual Notice of Changes for Blue Medicare Advantage Choice (PPO) (PDF, 9.1mb)
  (document 37-035 06/25)
  Available in these counties: Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Ellsworth, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Lincoln, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Ottawa, Pottawatomie, Reno, Rice, Riley, Russell, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.
• 2026 Annual Notice of Changes for Blue Medicare Advantage Comprehensive (PPO) (PDF, 9.1mb)
  (document 37-037 06/25)
  Available in these counties: Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Ellsworth, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Lincoln, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Ottawa, Pottawatomie, Reno, Rice, Riley, Russell, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.
• 2026 Annual Notice of Changes for Blue Medicare Advantage Freedom (PPO) (PDF, 8.9mb)
  (document 37-066 06/25)
  Available in these counties: Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Ellsworth, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Lincoln, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Ottawa, Pottawatomie, Reno, Rice, Riley, Russell, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.

Appointment of representative

• Appointment of Representative (PDF)
  (form CMS-1696)

Authorization forms

• Authorization for Release of Protected Health Information (PDF)
  (form 37-004)
• Revocation of Authorization for the Release of Protected Health Information (PDF)
  (form 37-009)
• Prior Authorization: Rehabilitation Assessment Form (PDF)
  (form 37-024)
• Prior Authorization: LTACH Assessment Form (PDF)
  (form 37-025)
• Prior Authorization: Inpatient Hospital Assessment Form (PDF)
  (form 37-026)
• Authorization Agreement for Automatic Payment Withdrawal (PDF)
  (form MC964)
• Waiver of Liability Statement (PDF)
  (form 37-038)

Claim forms

• International Claims Form (PDF)
  (form 18-059-N35)
• Member Claim Form (PDF)
  (form 34-4)
• Member Reimbursement Form (PDF)
  (form H7063_IGPAYSUBR_C)

Complaints

• For information about how to file a Medicare complaint, see Medicare - Claims, Appeals and Complaints

Disaster or emergency policies

• Getting Care in a Disaster or Emergency

Disenrollment forms

• Request for Disenrollment Form (PDF)

Doctor and pharmacy directories

Search the following for a new doctor, hospital, dentist or other health care provider.

• Search for Doctors and Hospitals
  • Provider Directory for Kansas Preferred Blue Medicare Advantage Network (PDF)
    (document 37-027)
• Search for Dentists
• Search for Pharmacies
  • 2025 Pharmacy Directory for Blue Medicare Advantage (PPO), Blue Medicare Advantage Comprehensive (PPO) and Blue Medicare Advantage Choice (PPO) (PDF)
    (document 37-028)
  • 2026 Pharmacy Directory for Blue Medicare Advantage (PPO), Blue Medicare Advantage Comprehensive (PPO) and Blue Medicare Advantage Choice (PPO) (PDF)
    (document 37-028)

Enrollment forms

• 2025 Enrollment in Blue Medicare Advantage Freedom (PPO), Blue Medicare Advantage Choice (PPO), and Blue Medicare Advantage Comprehensive (PPO) for Allen, Anderson, Bourbon, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Douglas, Elk, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Neosho, Osage, Pottawatomie, Reno, Riley, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson counties (PDF)
  (form 37-001 03/25)
• 2025 Enrollment in Blue Medicare Advantage (PPO) for Chase, Coffey, Douglas, Franklin, Geary, Jackson, Jefferson, Leavenworth, Linn, Lyon, Miami, Morris, Osage, Pottawatomie, Riley, Shawnee and Wabaunsee counties (PDF)
  (form 37-001N 03/25)
• 2025 Enrollment in Blue Medicare Advantage (PPO) for Butler, Cowley, Dickinson, Harvey, Kingman, Marion, McPherson, Reno, Sedgwick and Sumner counties (PDF)
  (form 37-001W 03/25)
• 2026 Enrollment in Blue Medicare Advantage Freedom (PPO), Blue Medicare Advantage Choice (PPO), and Blue Medicare Advantage Comprehensive (PPO) for Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Ellsworth, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Lincoln, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Ottawa, Pottawatomie, Reno, Rice, Riley, Russell, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson counties (PDF)
  (form 37-001 09/25)
• 2026 Enrollment in Blue Medicare Advantage (PPO) for Chase, Coffey, Douglas, Franklin, Geary, Jackson, Jefferson, Leavenworth, Linn, Lyon, Miami, Morris, Osage, Pottawatomie, Riley, Shawnee and Wabaunsee counties (PDF)
  (form 37-001N 09/25)
• 2026 Enrollment in Blue Medicare Advantage (PPO) for Butler, Cowley, Dickinson, Harvey, Kingman, Marion, McPherson, Reno, Sedgwick and Sumner counties (PDF)
  (form 37-001W 09/25)

Evidence of coverage

Find all the details about your plan. Consider this your owner's manual for your BCBSKS Medicare Advantage plan.

For information about how to file a Medicare claim, appeal or complaint, see Claims, Appeals and Complaints

• 2025 Evidence of Coverage for Blue Medicare Advantage (PPO) for Chase, Coffey, Douglas, Franklin, Geary, Jackson, Jefferson, Leavenworth, Linn, Lyon, Miami, Morris, Osage, Pottawatomie, Riley, Shawnee and Wabaunsee counties (PDF)
  (document 37-011 06/24)
• 2025 Evidence of Coverage for Blue Medicare Advantage (PPO) for Butler, Cowley, Dickinson, Harvey, Kingman, Marion, McPherson, Reno, Sedgwick and Sumner counties (PDF)
  (document 37-013 06/24)
• 2025 Evidence of Coverage for Blue Medicare Advantage Comprehensive (PPO) (PDF)
  (document 37-014 06/24)
  Available in these counties: Butler, Chase, Coffey, Cowley, Dickinson, Douglas, Franklin, Geary, Harvey, Jackson, Jefferson, Kingman, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Morris, Osage, Pottawatomie, Reno, Riley, Sedgwick, Shawnee, Sumner and Wabaunsee.
• 2025 Evidence of Coverage for Blue Medicare Advantage Choice (PPO) (PDF)
  (document 37-012 06/24)
  Available in these counties: Butler, Chase, Coffey, Cowley, Dickinson, Douglas, Franklin, Geary, Harvey, Jackson, Jefferson, Kingman, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Morris, Osage, Pottawatomie, Reno, Riley, Sedgwick, Shawnee, Sumner and Wabaunsee.
• 2025 Evidence of Coverage for Blue Medicare Advantage Freedom (PPO) (PDF)
  (document 37-061 06/24)
  Available in these counties: Butler, Chase, Coffey, Cowley, Dickinson, Douglas, Franklin, Geary, Harvey, Jackson, Jefferson, Kingman, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Morris, Osage, Pottawatomie, Reno, Riley, Sedgwick, Shawnee, Sumner and Wabaunsee.
• 2026 Evidence of Coverage for Blue Medicare Advantage (PPO) for Chase, Coffey, Douglas, Franklin, Geary, Jackson, Jefferson, Leavenworth, Linn, Lyon, Miami, Morris, Osage, Pottawatomie, Riley, Shawnee and Wabaunsee counties (PDF, 11.4mb)
  (document 37-011 06/25)
• 2026 Evidence of Coverage for Blue Medicare Advantage (PPO) for Butler, Cowley, Dickinson, Harvey, Kingman, Marion, McPherson, Reno, Sedgwick and Sumner counties (PDF, 11.4mb)
  (document 37-013 06/25)
• 2026 Evidence of Coverage for Blue Medicare Advantage Comprehensive (PPO) (PDF, 11.4mb)
  (document 37-014 06/25)
  Available in these counties: Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Ellsworth, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Lincoln, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Ottawa, Pottawatomie, Reno, Rice, Riley, Russell, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.
• 2026 Evidence of Coverage for Blue Medicare Advantage Choice (PPO) (PDF, 11.4mb)
  (document 37-012 06/25)
  Available in these counties: Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Ellsworth, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Lincoln, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Ottawa, Pottawatomie, Reno, Rice, Riley, Russell, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.
• 2026 Evidence of Coverage for Blue Medicare Advantage Freedom (PPO) (PDF, 11.4mb)
  (document 37-061 06/25)
  Available in these counties: Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Ellsworth, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Lincoln, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Ottawa, Pottawatomie, Reno, Rice, Riley, Russell, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.

Health and wellness programs forms

• Health Coaching Enrollment Form (Disease and Wellness Management Program)
• Strive+ Activity Coupon Form (PDF)

Low income subsidy premium

• 2025 Low Income Subsidy Premium for Blue Medicare Advantage plans for Allen, Anderson, Bourbon, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Douglas, Elk, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Neosho, Osage, Pottawatomie, Reno, Riley, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson counties (PDF)
  (document 37-030 09/24)
• 2026 Low Income Subsidy Premium for Blue Medicare Advantage plans for Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Ellsworth, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Lincoln, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Ottawa, Pottawatomie, Reno, Rice, Riley, Russell, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson counties (PDF)
  (document 37-030 09/25)

Lucet medical policies

• Lucet Medical Policies

Medical policies

• Access - Utilization Management Medical Policy (requires login)
• Policy - Diabetic Testing Supplies Prior Authorization with Benefit Limit Criteria (Prime Therapeutics, PDF)
• Policy - Continuous Glucose Monitoring Systems Benefit Limit Criteria (Prime Therapeutics, PDF)
• Policy - Dental Utilization Review Guidelines (Dominion National, PDF)

Member portal

• Medicare Advantage Member Portal Transition Letter (PDF)

Multi-language interpreter services

• Multi-Language Interpreter Services Insert (PDF)

Nondiscrimination and accessibility statement and notice

• Nondiscrimination and Accessibility Statement (PDF)

Prescription drug formulary

Start here to find out which of your prescription drugs are covered and what the cost will be for you.

• 2025 Formulary for Blue Medicare Advantage (PPO), Blue Medicare Advantage Comprehensive (PPO) and Blue Medicare Advantage Choice (PPO) (PDF)
  (document 37-029A)
• 2026 Formulary for Blue Medicare Advantage (PPO), Blue Medicare Advantage Comprehensive (PPO) and Blue Medicare Advantage Choice (PPO) (PDF)
  (document 37-029A)

Prescription drug formulary transition policy

• Download Medicare Formulary Transition Policy (.doc)

Social Security deduction application

• Social Security Deduction Application (PDF)
  (form MC965)

Star rating

• 2025 Medicare Star Ratings (PDF)

Summary of benefits

These documents are intended to help you better understand your coverage, and summarizes key features, such as what is covered, how much you might owe for certain services and details about services and procedures that may not be covered.

• 2025 Summary of Benefits for Blue Medicare Advantage (PPO) for Chase, Coffey, Douglas, Franklin, Geary, Jackson, Jefferson, Leavenworth, Linn, Lyon, Miami, Morris, Osage, Pottawatomie, Riley, Shawnee and Wabaunsee (PDF)
  (document 37-018 09/24)
• 2025 Summary of Benefits for Blue Medicare Advantage (PPO) for Butler, Cowley, Dickinson, Harvey, Kingman, McPherson, Marion, Reno, Sedgwick and Sumner counties (PDF)
  (document 37-017 09/24)
• 2025 Summary of Benefits for Blue Medicare Advantage Choice (PPO) (PDF)
  (document 37-044 09/24)
  Available in these counties: Allen, Anderson, Bourbon, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Douglas, Elk, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Neosho, Osage, Pottawatomie, Reno, Riley, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.
• 2025 Summary of Benefits for Blue Medicare Advantage Comprehensive (PPO) (PDF)
  (document 37-062 09/24)
  Available for these counties: Allen, Anderson, Bourbon, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Douglas, Elk, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Neosho, Osage, Pottawatomie, Reno, Riley, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.
• 2025 Summary of Benefits for Blue Medicare Advantage Freedom (PPO) (PDF)
  (document 37-063 09/24)
  Available for these counties: Allen, Anderson, Bourbon, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Douglas, Elk, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Neosho, Osage, Pottawatomie, Reno, Riley, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.
• 2026 Summary of Benefits for Blue Medicare Advantage (PPO) for Chase, Coffey, Douglas, Franklin, Geary, Jackson, Jefferson, Leavenworth, Linn, Lyon, Miami, Morris, Osage, Pottawatomie, Riley, Shawnee and Wabaunsee (PDF, 8.7mb)
  (document 37-018 08/25)
• 2026 Summary of Benefits for Blue Medicare Advantage (PPO) for Butler, Cowley, Dickinson, Harvey, Kingman, McPherson, Marion, Reno, Sedgwick and Sumner counties (PDF, 8.7mb)
  (document 37-017 08/25)
• 2026 Summary of Benefits for Blue Medicare Advantage Choice (PPO) (PDF, 8.7mb)
  (document 37-044 08/25)
  Available in these counties: Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Ellsworth, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Lincoln, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Ottawa, Pottawatomie, Reno, Rice, Riley, Russell, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.
• 2026 Summary of Benefits for Blue Medicare Advantage Comprehensive (PPO) (PDF, 8.7mb)
  (document 37-062 08/25)
  Available in these counties: Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Ellsworth, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Lincoln, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Ottawa, Pottawatomie, Reno, Rice, Riley, Russell, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.
• 2026 Summary of Benefits for Blue Medicare Advantage Freedom (PPO) (PDF, 8.7mb)
  (document 37-063 08/25)
  Available in these counties: Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Ellsworth, Franklin, Geary, Greenwood, Harper, Harvey, Jackson, Jefferson, Kingman, Labette, Leavenworth, Lincoln, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Ottawa, Pottawatomie, Reno, Rice, Riley, Russell, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Woodson.