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
View these forms and documents in Spanish. If you have questions, please Contact Us.
General Plan Information
- Automated Premium Payment (ACH) Form (DSNP)
- Automated Premium Payment (ACH) Form (MAPD)
- Automated Premium Payment (ACH) Form (PDP)
- CMS Appointment of Representative Form
Prescription Drug Information
- Mail-Order Physician New Prescription Fax Form
- Medicare Part B vs. Part D Form
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List (DSNP, MAPD, and DSNP )
- Pharmacy Mail-Order Form
- Prescription Drug Claim Form
- Prescription Drug Coverage Determination Request Form (DSNP)
- Prescription Drug Coverage Determination Request Form (MAPD)
- Prescription Drug Coverage Determination Request Form (PDP)
- Prescription Drug Coverage Redetermination Request Form (DSNP)
- Prescription Drug Coverage Redetermination Request Form (MAPD)
- Prescription Drug Coverage Redetermination Request Form (PDP)
- Prescription Drug Formulary Exception Physician Form
- Prescription Drug Tier Exception Physician Form
Other
- Access Additional Privacy Forms
- Authorization to Disclose Protected Health Information (PHI) Form
- Late Enrollment Penalty (LEP) Appeals
- Notice of Privacy Practices
If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form or contact the Office of the Medicare Ombudsman.
General Plan Information
- Automated Premium Payment (ACH) Form (DSNP)
- Automated Premium Payment (ACH) Form (MAPD)
- Automated Premium Payment (ACH) Form (PDP)
- CMS Appointment of Representative Form
Prescription Drug Information
- Mail-Order Physician New Prescription Fax Form
- Medicare Part B vs. Part D Form
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List (DSNP, MAPD, and DSNP )
- Pharmacy Mail-Order Form
- Prescription Drug Claim Form
- Prescription Drug Coverage Determination Request Form (DSNP)
- Prescription Drug Coverage Determination Request Form (MAPD)
- Prescription Drug Coverage Determination Request Form (PDP)
- Prescription Drug Coverage Redetermination Request Form (DSNP)
- Prescription Drug Coverage Redetermination Request Form (MAPD)
- Prescription Drug Coverage Redetermination Request Form (PDP)
- Prescription Drug Formulary Exception Physician Form
- Prescription Drug Tier Exception Physician Form
Other
- Access Additional Privacy Forms
- Authorization to Disclose Protected Health Information (PHI) Form
- Late Enrollment Penalty (LEP) Appeals
- Notice of Privacy Practices
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 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
Late Enrollment Penalty (LEP) Appeals
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: Oct. 01, 2022
Last Updated: 09302022
Y0096_WEBNMMM23