Medicare Advantage Plan Resources

For more information about your CareFirst BlueCross BlueShield Medicare Advantage plan or appropriate forms, please select from the resources below.

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CareFirst BlueCross BlueShield Advantage DualPrime (HMO SNP)

Resource information for our CareFirst BlueCross BlueShield Advantage DualPrime plan can be found here.

Documents

Health Evaluation Icon Summary of Benefits - Service Area 1 (PDF)
English | Spanish
Health Evaluation Icon Summary of Benefits - Service Area 2 (PDF)
English | Spanish
Health Evaluation Icon Evidence of Coverage - Core (PDF)
English | Spanish
Health Evaluation Icon Evidence of Coverage - Enhanced (PDF)
English | Spanish
Health Evaluation Icon Formulary - Core (PDF)
English | Spanish
Health Evaluation Icon Formulary - Enhanced (PDF)
English | Spanish
Health Evaluation Icon Pharmacy Directory (PDF)
English | Spanish
Health Evaluation Icon Provider Directory (PDF)
English | Spanish
Health Evaluation Icon Top 100 Drugs (PDF)
English | Spanish
Health Evaluation Icon LIS Premium Summary Chart (PDF)
English | Spanish
Health Evaluation Icon Attestation Page (PDF)
English | Spanish
Health Evaluation Icon Pre-enrollment Information Kit - Service Area 1 (PDF)
English
Health Evaluation Icon Pre-enrollment Information Kit - Service Area 2 (PDF)
English
Health Evaluation Icon Enrollment Application (PDF)
English | Spanish
Health Evaluation Icon Notice of Privacy Practices (PDF)
English | Spanish
Health Evaluation Icon Bank Account Withdrawal Pre-Authorization Form (PDF)
English
Health Evaluation Icon Annual Notice of Changes - Core (PDF)
English | Spanish
Health Evaluation Icon Annual Notice of Changes - Enhanced (PDF)
English | Spanish
Health Evaluation Icon Designation of Personal Representative Form (PDF)
English
Health Evaluation Icon Medicare Star Ratings (PDF)
English | Spanish
Health Evaluation Icon Part D Star Ratings (PDF)
English | Spanish

Member Forms

Utilization Management Forms
Health Evaluation Icon Quantity Limit Exception Form (PDF) English | Spanish
Health Evaluation Icon Step Therapy Exception Form (PDF) English | Spanish

Prior Authorization Forms
Health Evaluation Icon Prior Authorization - DME (PDF) English | Spanish
Health Evaluation Icon Prior Authorization - Home Care (PDF) English | Spanish
Health Evaluation Icon Prior Authorization - OPAP (PDF) English | Spanish
Health Evaluation Icon Prior Authorization - Pre Service Review Request (PDF) English | Spanish

Request for Reconsideration Forms
Health Evaluation Icon Reconsideration Request Form - Core (PDF) English
Health Evaluation Icon Reconsideration Request Form - Enhanced (PDF) English

Provider Forms

Utilization Management Forms
Health Evaluation Icon Quantity Limit Exception Form (PDF) English | Spanish
Health Evaluation Icon Step Therapy Exception Form (PDF) English | Spanish

Exception Request Forms
Health Evaluation Icon Tiering Exception Form (PDF) English | Spanish
Health Evaluation Icon Non-Formulary Exception Form (PDF) English | Spanish

Prior Authorization Forms
Health Evaluation Icon Prior Authorization - DME (PDF) English | Spanish
Health Evaluation Icon Prior Authorization - Home Care (PDF) English | Spanish
Health Evaluation Icon Prior Authorization - OPAP (PDF) English | Spanish
Health Evaluation Icon Prior Authorization - Pre Service Review Request (PDF) English | Spanish
Health Evaluation Icon Waiver of Liability Statement (PDF) English
 

General Resources

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Medicare During COVID-19

See how Medicare is responding to the ongoing COVID-19 pandemic.

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Caregiver Resources

Do you care for someone that needs Medicare? Here's what you need to know.

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Medicare Cost Assistance

Need help paying for Medicare? Assistance is available.

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Avoid Paying Penalties

Know when to enroll in Medicare to save money.

 

Ways to Enroll

By Mail
Complete an application

Send your completed application to:
CareFirst BlueCross BlueShield Medicare Advantage
P.O. Box 3236
Scranton, PA 18505

By Phone
Speak to a licensed sales agent by calling 833-987-0765 (TTY: 711) Monday through Friday 8am through 6pm ET and Saturday 8am through 12pm.

Online
You can access our online enrollment application by the Enroll button or by visiting Medicare.gov and accessing Plan Finder.

 

Next Steps

Now that you've applied for a Medicare Advantage plan, what happens next?

  • First, we'll review your enrollment application to make sure it's complete. We'll also double-check that you meet all eligibility requirements.
  • Next, we'll send you a letter or email to confirm that we've received your enrollment form. We'll also let Medicare know that you've applied to join one of our plans.
  • Within 10 calendar days of Medicare confirming your eligibility, we'll let you know when your CareFirst BlueCross Medicare Advantage plan coverage starts.
  • Shortly after that, we'll mail your new member welcome packet and your new member ID card. Your welcome packet will provide helpful information about how to get the most from your new plan.

If you have questions, please contact CareFirst BlueCross BlueShield Medicare Advantage Member Services at 855-290-5744 (TTY:711) 8 a.m.-8 p.m., ET, 7 days a week from October 1 through March 31. From April 1 through September 30, our hours are 8 a.m.-8 p.m., ET, Monday through Friday.

Rights and Responsibilities Upon Disenrollment

If you decide to disenroll, this means you are ending your plan membership. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice).

You can leave your plan for any reason; however, there are limits to when you can end your membership, how often you can make changes, and what type of plan you can join after you leave.

Usually, you end your membership by enrolling in another plan during a specific enrollment period (see question "When can you end your membership" listed below). But there are two ways you can ask to be disenrolled:

  1. Make a request in writing - Member Services by calling the number on the back of your ID card for more information on how to do this.
  2. Contact Medicare - call 800-MEDICARE (800-633-4227), 24 hours a day, 7 days a week. (TTY: 877-486-2048).

There are certain times of the year that all members can leave their Medicare Advantage plan.

  1. Annual Election Period
    All members can leave the plan during the Annual Election Period, which happens from October 15 to December 7. During this time, you can choose:
    • Another Medicare health plan, with or without prescription drug coverage
    • Original Medicare, with or without standalone drug coverage

    If you disenroll in our plan during the AEP, your membership will end when your new plan's coverage begins on January 1.
  2. Medicare Advantage Open Enrollment Period
    You can also send your membership during the Medicare Advantage Open Enrollment Period, from January 1 to March 31. During this time, you can:
    • Switch to a different Medicare Advantage plan, with or without prescription drug coverage
    • Return to Original Medicare (you will have until March 31 to join a separate Medicare prescription drug plan)
    If you disenroll in our plan during Open Enrollment, your membership will end on the first day of the month after we get your request to switch to Original Medicare. If you also choose to enroll in a Medicare prescription drug plan, your coverage will begin the first day of the month after the drug plan gets your enrollment request.
  3. Special Enrollment Period
    In certain situations, you may be eligible to end your membership at other times of the year if you qualify for a Special Enrollment Period (SEP). To see a full list of examples of situations that meet the criteria for Special Enrollment, visit medicare.gov.

    To find out if you are eligible for a Special Enrollment Period, please call Medicare at 800-MEDICARE (800-633-4227), 24 hours a day, 7 days a week. (TYY: 877-486-2048).
 
 

Other things to be aware of:

  • If you receive "Extra Help" from Medicare to pay for your prescription drugs: If you want to switch to Original Medicare and do not enroll in a separate prescription drug plan, Medicare may enroll you in a drug plan, unless you have opted out of automatic enrollment.
  • Try to avoid going without Medicare prescription drug coverage for over 63 days: You may have to pay a Part D late enrollment penalty if you join a Medicare drug plan later.
  • Until your membership ends, you must keep getting your medical services and drugs through our plan: You should continue to use our network pharmacies and, if you're hospitalized on the day your membership ends, you'll usually be covered by our plan until you are discharged (even if it's after your new coverage begins).
 

Questions? Need more information?

For more on disenrollment, see chapter 10 in your Evidence of Coverage (EOC), which includes detailed information about:

  • Ending your membership in the plan
  • When you can end your membership
  • How to end membership
  • Situations where CareFirst BlueCross BlueShield Medicare Advantage must end your membership

Please call our Member Services team at 855-290-5744 (TTY: 711) with questions. Our Member Services hours are 8 a.m.-8 p.m., ET, 7 days a week from October 1 through March 31. From April 1 through September 30, our hours are 8 a.m.-8 p.m., ET, Monday through Friday.

 

How to Appoint a Representative (AOR Form)

You may appoint a personal representative who will act on your behalf in making decisions related to healthcare, which includes treatment and payment issues, as well as filing an appeal.

This individual can be:

  • A family member
  • A friend
  • A lawyer
  • An unrelated party

To appoint a representative, please complete the CMS Appointment of Representative form and send to:

Fax: 443-753-2298

Mail: CareFirst BlueCross BlueShield Medicare Advantage
P.O. Box 3626
Scranton, PA 18505

Please keep a copy of the Appointment of Representative form for your records.

 

Part C Medical Coverage Determination, Grievances and Appeals

Members have a right to request an organization determination. (To keep things simple, we use "coverage decision" rather than "organization determination.") If the plan denies coverage for your requested item or service, you have the right to appeal and ask us to reconsider the decision. You also have a right to file a grievance (also called a complaint) about the health plan.

 

COVERAGE DETERMINATION

A coverage decision is any decision made by the plan regarding:

  • Receipt of, or payment for, a care item or service
  • The amount you pay for an item or service
  • A limit on the quantity of items or services

Any time that we make a decision about what we will cover and how much we will pay for your medical services or drugs, we are making a coverage decision.

Members have a right to request a coverage decision. If the plan denies coverage for your requested item or service, you have the right to appeal and ask us to reconsider the decision. You also have a right to file a grievance (also called a complaint) about the health plan.

You can mail your coverage determination in writing or contact our member services team for more options to submit your Part C Medical coverage determination.

To request a coverage decision regarding medical care you or your representative may:

Mail:
CareFirst BlueCross BlueShield Preservice Review Department
10455 Mill Run Circle, Room 11113-A
Owings Mills, MD 21117

To request a coverage decision regarding payment for medical care you already received you or your representative may:

Mail:
CareFirst BlueCross BlueShield Medicare Advantage Claims
P.O. Box 4495
Scranton, PA 18505

You can call Member Services to request information on a coverage determination or to request an expedited coverage determination verbally.

Concerns about the plan are important to us. For immediate attention to your grievance, you can call our Member Services to submit your grievance verbally for us to assist you in resolving your concerns.

Call:
855-290-5744

Our Member Services hours are 8 a.m.-8 p.m., ET, 7 days a week from October 1 through March 31. From April 1 through September 30, our hours are 8 a.m. - 8 p.m., ET, Monday through Friday.

Under certain circumstances you can request an expedited coverage decision which is also called a "fast coverage decision." A fast coverage decision means that we will make a decision no later than 72 hours after receiving the request.

To get a "fast coverage decision" you must meet both of the following requirements:

  • You are asking for coverage for medical care you have not yet received
  • Using the standard deadlines could cause serious harm to your health or hurt your ability to function. If we determine that your request does not meet the criteria above, then it will be handled as a standard coverage decision

GRIEVANCES

A grievance is any complaint or dispute expressing dissatisfaction with any aspect of our operations, including our Medicare plans, Member Services, your provider or treatment facility.

You can submit a grievance at any time. You also have the right to withdraw a grievance.

You can file a grievance within sixty (60) calendar days of the date of the circumstance giving rise to the grievance.

The grievance will be sent to our Appeals and Grievance Department for handling. The plan's response may take 30 days or up to 44 days if more information is needed.

Concerns about the plan are important to us. For immediate attention to your grievance, you can call our Member Services to submit your grievance verbally for us to assist you in resolving your concerns.

Call:
855-290-5744

Our Member Services hours are 8 a.m.-8 p.m., ET, 7 days a week from October 1 through March 31. From April 1 through September 30, our hours are 8 a.m. - 8 p.m., ET, Monday through Friday.

You can also fax or mail your grievance in writing to us at:

Fax:
443-753-2298

Mail:
CareFirst BlueCross BlueShield Medicare Advantage
P.O. Box 3626
Scranton, PA 18505

You can also submit a complaint about your plan directly to Medicare.

Online:
Complete the Medicare Complaint Form

 
 

APPEALS

There are two types of appeals: standard appeals and expedited appeals.

1. Standard Appeals

You have the right to file an appeal if CareFirst BlueCross BlueShield did not approve or pay for services you believe should be covered or provided. This would be a standard appeal for benefits (pre-service appeal) or payment of a claim (payment appeal).

If a standard appeal is filed, we will send you a decision within:

  • 7 days if the appeal is regarding a request for a pre-service Part B drug that a member wants to receive
  • 30 days if the appeal is regarding a pre-service request for coverage of a benefit or service that a member wants to receive
  • 60 days for an appeal for payment for a service or Part B drug that was already received.

2. Expedited Appeals

If you believe waiting for a decision will seriously harm your health, you can ask that we process the appeal in an expedited manner. A CareFirst BlueCross BlueShield representative will contact you with a decision within 72 hours.

To file an expedited appeal, call Member Services at 855-290-5744 for assistance. You can also submit an expedited appeal in writing.

Fax for Clinical Pre-Service Expedited Appeals:
410-605-2566

Mail:
CareFirst BlueCross BlueShield Medicare Advantage
Clinical Appeals and Analysis
10455 Mill Run Circle, Room 11113-A
Owings Mills, MD 21117

 

When can you submit a standard appeal?

Standard Payment Appeals

You can file a standard payment appeal within sixty (60) calendar days of the date of the notice of our initial determination. That timeframe may be extended if good cause exists.

All standard claims payment appeals must be submitted in writing to:

CareFirst BlueCross BlueShield Medicare Advantage
P.O. Box 3626
Scranton, PA 18505

Standard Pre-service Appeals

You can file a standard pre-service appeal within sixty (60) calendar days of the date of the notice of our initial determination. That timeframe may be extended if good cause exists.

All standard pre-service appeals for a service or Part B drug a member wants to receive must be submitted in writing to:

CareFirst BlueCross BlueShield Medicare Advantage
Clinical Appeals and Analysis
10455 Mill Run Circle, Room 11113-A
Owings Mills, MD 21117

Expedited Appeals

If you believe waiting for a decision will seriously harm your health, you can ask that we process the appeal in an expedited manner. A CareFirst BlueCross BlueShield representative will contact you with a decision within 72 hours.

To file an expedited appeal, call Member Services at 855-290-5744 for assistance. You can also submit an expedited appeal in writing.

Fax for Clinical Pre-Service Expedited Appeals:
410-605-2566

Mail:
CareFirst BlueCross BlueShield Medicare Advantage
Clinical Appeals and Analysis
10455 Mill Run Circle, Room 11113-A
Owings Mills, MD 21117

 

Need more information? Questions?

For more information about our process for appeals, grievances and coverage decisions, see Chapter 9 of your Evidence of Coverage (EOC).

To obtain the total number of grievances, appeals, and exceptions filed with the us, you should send a written request to:

Fax:
443-753-2298

Mail:
CareFirst BlueCross BlueShield Medicare Advantage
P.O. Box 3626
Scranton, PA 18505

For more information, call member services at 855-290-5744 (TTY:711) 8 a.m.- 8 p.m. ET, 7 days a week from October 1 through March 31. From April 1 through September 30, our hours are 8 a.m.-8 p.m., ET, Monday through Friday.