Forms & Documents | Blue Cross and Blue Shield of New Mexico

This page may have documents that can’t be read by screen reader software. For help with these documents, please call 1-877-774-8592.

Forms and Documents

Find Medicare Advantage, Medicare Advantage Dual Care Plus (HMO SNP), Medicare Advantage Dual Care Plus Preferred (PPO 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 Plus (HMO SNP)SM and Blue Cross Medicare Advantage Dual Care Plus Preferred (PPO SNP)SM Plan Documents

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 Pharmacy Mail-Order 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.

2022 Personal Medication List (MAPD, PDP, DSNP) English | español

2022 Mail-Order Physician New Prescription Fax Form

2022 Pharmacy Mail-Order Form

2022 Prescription Drug Claim Form

2022 Medicare Part B vs. Part D Form

2022 Authorization to Disclose Protected Health Information (PHI) Form

2022 CMS Appointment of Representative Form (PDP)

2022 CMS Appointment of Representative Form (MAPD)

2022 CMS Appointment of Representative Form (DSNP)

2022 Notice of Privacy Practices

2022 Access Additional Privacy Forms

2022 Automated Premium Payment (ACH) Form (PDP)

2022 Automated Premium Payment (ACH) Form (MAPD)

2022 Automated Premium Payment (ACH) Form (DSNP)

2022 Prescription Drug Coverage Determination Request Form (PDP) English | español

2022 Prescription Drug Coverage Redetermination Request Form (PDP) English | español

2022 Prescription Drug Coverage Determination Request Form (HMO, PPO) English | español

2022 Prescription Drug Coverage Redetermination Request Form (HMO, PPO) English | español

2022 Prescription Drug Coverage Determination Request Form (HMO SNP, PPO SNP) English | español

2022 Prescription Drug Coverage Redetermination Request Form (HMO SNP, PPO SNP) English | español

2022 Online Coverage Determination Request Form

2022 Online Coverage Redetermination Request Form

2022 Prescription Drug Formulary Exception Physician Form

2022 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.