Forms and Documents
Find Medicare Advantage, Medicare Advantage Dual Care (HMO SNP), prescription drug, Medicare Supplement and other forms you need to help you manage your Medicare plan.
Blue Cross Medicare AdvantageSM Plans Documents
Blue Cross MedicareRx (PDP)SM Plan Documents
Blue Medicare Supplement InsuranceSM (Medigap) Plan Documents
Blue Cross Medicare Advantage Dual Care (HMO SNP)SM Plan Documents
2020 Online Coverage Determination Request Form
2020 Online Coverage Redetermination Request Form
2020 Mail-Order Physician New Prescription Fax Form
2020 Prescription Drug Claim Form
2020 Medicare Part B vs. Part D Form
2020 Authorization to Disclose Protected Health Information (PHI) Form
2020 CMS Appointment of Representative Form
2020 Notice of Privacy Practices
2020 Access Additional Privacy Forms
2020 Automated Premium Payment (ACH) Form
2020 Automated Premium Payment (ACH) Form (PDP)
2020 Automated Premium Payment (ACH) Form (MAPD)
2020 Automated Premium Payment (ACH) Form (DSNP)
2020 Prescription Drug Coverage Determination Request Form (PDP)
2020 Prescription Drug Coverage Redetermination Request Form (PDP)
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Prescription Drug Coverage Determination Request Form (DSNP)
2020 Prescription Drug Coverage Redetermination Request Form (DSNP)
2020 Prescription Drug Formulary Exception Physician Form
2020 Prescription Drug Tier Exception Physician Form
If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form or contact the Office of the Medicare Ombudsman.
2021 Personal MedicationList (PDP) English | español
2021 Personal Medication List (MAPD) English | español
2021 Personal Medication List (DSNP) English | español
2021 Mail-Order Physician New Prescription Fax Form
2021 Prescription Drug Claim Form
2021 Medicare Part B vs. Part D Form
2021 Authorization to Disclose Protected Health Information (PHI) Form
2021 CMS Appointment of Representative Form (PDP)
2021 CMS Appointment of Representative Form (MAPD)
2021 CMS Appointment of Representative Form (DSNP)
2021 Notice of Privacy Practices
2021 Access Additional Privacy Forms
2021 Automated Premium Payment (ACH) Form (PDP)
2021 Automated Premium Payment (ACH) Form (MAPD)
2021 Automated Premium Payment (ACH) Form (DSNP)
2021 Prescription Drug Coverage Determination Request Form (PDP) English | español
2021 Prescription Drug Coverage Redetermination Request Form (PDP) English | español
2021 Prescription Drug Coverage Determination Request Form (HMO) English | español
2021 Prescription Drug Coverage Redetermination Request Form (HMO) English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Prescription Drug Coverage Determination Request Form (DSNP) English | español
2021 Prescription Drug Coverage Redetermination Request Form (DSNP) English | español
2021 Online Coverage Determination Request Form
2021 Online Coverage Redetermination Request Form
2021 Prescription Drug Formulary Exception Physician Form
2021 Prescription Drug Tier Exception Physician Form
If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form or contact the Office of the Medicare Ombudsman.
Last Updated: 09302020
Y0096_WEBNMMM21
Last Updated: 09302020
Y0096_WEBNMMM21