Useful Links

Summary of Benefits

Multi-Language Interpreter Services

Do you need plan information in a different format?

Current Annual Notice of Change/Evidence of Coverage

Current Provider Directory

Privacy Notice under the HIPAA Privacy Rule

Current Medicare Star Ratings

Current List of Covered Drugs (Formulary)

Utilization Management Documents

Documents include Step Therapy Guidelines, Medication Therapy Management, Prior Authorization Requirements and more.

Prescription Drug Transition Policy

Extra Help from Medicare (low-income subsidy Premium Summary Chart)

You might qualify to get help in paying for your drugs.

Request for Coverage Determination/Redetermination Forms

Exception and Appeal Forms

Understand the process for coverage decisions, how to request an appeal, and who to contact with questions related to benefits and coverage for medical services and prescription drugs. 

CMS Appoint a Representative Form

You can appoint a representative – like a family member, friend, advocate, attorney, doctor or someone else – to act on your behalf.



This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. 

Out-of-network/non-contracted providers are under no obligation to treat BlueShield of Northeastern New York members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. 

Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

BlueShield of Northeastern New York is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal.

A division of HealthNow New York Inc., and independent licensee of the BlueCross BlueShield Association. A salesperson will be present with information and applications. For accommodations of persons with special needs at sales meetings, please call 1-800-329-2792 (TTY 711). BlueShield of Northeastern New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-329-2792 (TTY: 711).

注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-800-329-2792 (TTY: 711).

Y0086_MRK1962 Approved
Content Last Updated October 1, 2017