My Plan and Coverage Information
- Summary of Benefits
Provides a summary of payment and coverage information - Evidence of Coverage
Contains a full breakdown of payment and coverage information - Request a hard copy of an EOC
- Annual Notice of Changes
Details specific changes made to plan at the start of each plan year - Annual Notice of Change BluePathway Plan 2 (ANOC)
- Annual Notice of Change BluePathway Plan 3 (ANOC)
- Notificación anual de modificaciones BluePathway Plan 2 (ANOC)
- Notificación anual de modificaciones BluePathway Plan 3 (ANOC)
- Directories
- Request a hard copy of a Directory
- Provider & Dental Directories (Directorio de Proveedores, Directorio de Proveedores Dental)
- Pharmacy & Prescription Drugs (Directorio de Farmacias, Formulario)
- Requesting a Person to Represent Me or Have Access to My Confidential Information
- Appointing a Representative - You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.
- Nombramiento de un Representante
- Use the Plan's Coverage for your Medical Services
- Out-of-Network Coverage Rules - How to get care from out-of-network providers or pharmacies.
- Enrollment Forms
Authorization Agreement for Automatic Deposits
- Direct Member Reimbursement Form-Request reimbursement for covered medical care and supplies that were paid out-of-pocket.
My Plan and Coverage Information
- Evidence of Coverage
Contains a full breakdown of payment and coverage information - Request a hard copy of an EOC
- Annual Notice of Changes
Details specific changes made to plan at the start of each plan year - Annual Notice of Change BluePathway Plan 2 (ANOC)
- Notificación anual de modificaciones BluePathway Plan 2 (ANOC)
- Directories
- Request a hard copy of a Directory
- Provider & Dental Directories (Directorio de Proveedores, Directorio de Proveedores Dental)
- Pharmacy & Prescription Drugs (Directorio de Farmacias, Formulario)
- Requesting a Person to Represent Me or Have Access to My Confidential Information
- Appointing a Representative - You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.
- Nombramiento de un Representante
- Use the Plan's Coverage for your Medical Services
- Out-of-Network Coverage Rules - How to get care from out-of-network providers or pharmacies.
- Enrollment Forms
Authorization Agreement for Automatic Deposits
- Direct Member Reimbursement Form-Request reimbursement for covered medical care and supplies that were paid out-of-pocket.
My Plan and Coverage Information
- Summary of Benefits
Provides a summary of payment and coverage information - Evidence of Coverage
Contains a full breakdown of payment and coverage information - Request a hard copy of an EOC
- Annual Notice of Changes
Details specific changes made to plan at the start of each plan year - Directories
- Request a hard copy of a Directory
- Provider & Dental Directories (Directorio de Proveedores, Directorio de Proveedores Dental)
- Pharmacy & Prescription Drugs (Directorio de Farmacias, Formulario)
- Requesting a Person to Represent Me or Have Access to My Confidential Information
- Appointing a Representative - You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.
- Nombramiento de un Representante
- Use the Plan's Coverage for your Medical Services
- Out-of-Network Coverage Rules - How to get care from out-of-network providers or pharmacies.
- Enrollment Forms
Authorization Agreement for Automatic Deposits
- Direct Member Reimbursement Form-Request reimbursement for covered medical care and supplies that were paid out-of-pocket.
My Plan and Coverage Information
Electronic Funds Transfer (EFT) or ACH Authorization Form
- Summary of Benefits
Provides a summary of payment and coverage information - Evidence of Coverage
Contains a full breakdown of payment and coverage information - Request a hard copy of an EOC
- Annual Notice of Changes
Details specific changes made to plan at the start of each plan year - Directories
- Request a hard copy of a Directory
- Provider & Dental Directories (Directorio de Proveedores, Directorio de Proveedores Dental)
- Pharmacy & Prescription Drugs (Directorio de Farmacias, Formulario)
- Requesting a Person to Represent Me or Have Access to My Confidential Information
- Appointing a Representative - You may choose someone to act on your behalf. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.
- Nombramiento de un Representante
- Use the Plan's Coverage for your Medical Services
- Out-of-Network Coverage Rules - How to get care from out-of-network providers or pharmacies.
- Enrollment Forms
Authorization Agreement for Automatic Deposits
- Direct Member Reimbursement Form-Request reimbursement for covered medical care and supplies that were paid out-of-pocket.