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 Advantage^SM Plans Documents

Blue Cross MedicareRx (PDP)^SM Plan Documents

Blue Medicare Supplement Insurance^SM (Medigap) Plan Documents

Blue Cross Medicare Advantage Dual Care (HMO SNP)^SM Plan Documents

2018
2019

2018 Personal Medication List

2018 Online Coverage Determination Request Form

2018 Online Coverage Redetermination Request Form

2018 Mail-Order Physician New Prescription Fax Form

2018 Pharmacy Mail-Order Form

2018 Prescription Drug Claim Form

2018 Medicare Part B vs. Part D Form

2018 Authorization to Disclose Protected Health Information (PHI) Form

2018 CMS Appointment of Representative Form

2018 Notice of Privacy Practices

2018 Access Additional Privacy Forms

2018 Automated Premium Payment (ACH) Form

2018 Automated Premium Payment (ACH) Form (PDP)

2018 Automated Premium Payment (ACH) Form (MAPD)

2018 Automated Premium Payment (ACH) Form (DSNP)

2018 Prescription Drug Coverage Determination Request Form (PDP)

2018 Prescription Drug Coverage Redetermination Request Form (PDP)

2018 Prescription Drug Coverage Determination Request Form (MAPD)

2018 Prescription Drug Coverage Redetermination Request Form (MAPD)

2018 Prescription Drug Coverage Determination Request Form (DSNP)

2018 Prescription Drug Coverage Redetermination Request Form (DSNP)

2019 Personal Medication List

2019 Online Coverage Determination Request Form

2019 Online Coverage Redetermination Request Form

2019 Mail-Order Physician New Prescription Fax Form

2019 Pharmacy Mail-Order Form

2019 Prescription Drug Claim Form

2019 Medicare Part B vs. Part D Form

2019 Authorization to Disclose Protected Health Information (PHI) Form

2019 CMS Appointment of Representative Form

2019 Notice of Privacy Practices

2019 Access Additional Privacy Forms

2019 Automated Premium Payment (ACH) Form

2019 Automated Premium Payment (ACH) Form (PDP)

2019 Automated Premium Payment (ACH) Form (MAPD)

2019 Automated Premium Payment (ACH) Form (DSNP)

2019 Prescription Drug Coverage Determination Request Form (PDP)

2019 Prescription Drug Coverage Redetermination Request Form (PDP)

2019 Prescription Drug Coverage Determination Request Form (MAPD)

2019 Prescription Drug Coverage Redetermination Request Form (MAPD)

2019 Prescription Drug Coverage Determination Request Form (DSNP)

2019 Prescription Drug Coverage Redetermination Request Form (DSNP)