Forms and Translated Materials

Blue Cross Medicare Advantage
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Appointment of Representative
Authorization to Disclose Protected Health Information
Automated Premium Payment (ACH) Form
Prescription Drug Mail-Order Form
Prescription Drug Claim Form - HMO
Prescription Drug Claim Form - HMO-POS
Prescription Drug Claim Form - PPO
Prior Authorization
Request for Medicare Prescription Drug Coverage Determination Form
Request for Redetermination of Medicare Prescription Drug Denial Form
Physician Fax Form
File a Grievance (Please select your health plan and health plan type for information about filing a grievance.)
Step Therapy Form — HMO
Step Therapy Form — HMO-POS
Step Therapy Form — PPO

en Español

Alternate formats for these materials, including Spanish translations, may be available. Please contact our Product Specialists for additional information.

Este material está disponible en otros formatos, incluida la traducción al Español. Contacte nuestro numero de Servicio al Cliente para obtener información adicional.

Materials in English - 2014 Materiales en Español - 2014
Summary of Benefits - HMO  
Y0096_BEN_NM_MAPDSB14 Accepted 10012013
Summary of Benefits - PPO  
H8634_BEN_NM_MAPDSB14 Accepted 10012013
Summary of Benefits en Español- HMO  
Y0096_BEN_NM_MAPDSB14SPA Accepted 10012013
Drug List - HMO
Y0096_MRK_TMP_MAFRMLRY14 Accepted 10012013_NM HMO

Drug List - PPO
H8634_MRK_TMP_MAFRMLRY14 Accepted 10012013_NM PPO
Drug List - HMO en Español  
Y0096_MRK_TMP_MAFRMLRY14SPA_NM_HMO

Drug List - PPO en Español  
Y0096_MRK_TMP_MAFRMLRY14SPA_NM_PPO
Pharmacy Directory
Y0096_BEN_TMP_MAPHAR14 Accepted 10012013_NM
Pharmacy Directory en Español
Y0096_BEN_TMP_MAPHAR14SPA Accepted 10012013 NM

Evidence of Coverage- HMO
Y0096_BEN_NM_HMOANOCEOC2014a Accepted 09182013

Evidence of Coverage- HMO-POS
Y0096_BEN_NM_HMOPOSEOC2014 Accepted 09052013

Evidence of Coverage- PPO
H8634_BEN_NM_PPOEOC2014 Accepted 09052013

Evidence of Coverage- HMO en Español
Y0096_BEN_NM_HMOANOCEOC2014aSPA Accepted 09182013

Evidence of Coverage- HMO-POS en Español
Y0096_BEN_TMP_MAEOCCVR14SPA Approved 08222013

Evidence of Coverage- PPO en Español
H8634_BEN_TMP_MAEOCCVR14SPA Approved 08192013

 

Materials in English - 2013 Materiales en Español - 2013
Summary of Benefits  
H3822_NM_BEN_BNFTSMRY13 Accepted 09152012
Summary of Benefits en Español 
H3822_NM_BEN_BNFTSMRY13SPA Accepted 09152012
Drug List  
H3822_MRK_NM_TMP_FRMLRY13
Drug list en Español  
H3822_MRK_NM_TMP_FRMLRY13SPA
Pharmacy Directory  
H3822_BEN_TMP_RXDRCTRY13a Accepted 10012012
Pharmacy Directory en Español
H3822_BEN_TMP_RXDRCTRY13aSPA Accepted 10012012
Evidence of Coverage
H3822_BEN_NM_MAPDEOC2013 Accepted 09042012
Evidence of Coverage en Español
H3822_BEN_NM_MAPDEOC2013SPA Accepted 09052012