Blue Access for Producers

Downloadable Forms for Individual Products


Here are some commonly used forms and documents for conducting business with Blue Cross and Blue Shield of Texas (BCBSTX).

The forms below are in portable document format (PDF). To view these files, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader®.

Note: Please provide the Texas Department of Insurance Notice to your clients at the same time as you provide the Outline of Coverage.

PLEASE READ: Texas Department of Insurance required Disclosure Notice for all individual HMO Consumer Choice benefit plans issued in Texas.

2014 Individual Forms and Documents
Stock # / Date Enrollment Forms and Change Forms Texas Form #
57330.0313 Health Application/Change in Coverage  UN65-APP/Off-EX
725600.0813 Health Application/Change in Coverage (Spanish Version)  UN65-APP/Off-EX-SP
42780.0812 SelecTEMP PPO Application  PPO-STM-3-APP-3
725618.0813 SelecTEMP PPO Application (Spanish Version)  PPO-STM-3-APP-3
57784.0513 Dental Application/Change in Coverage  UN65-APP/Dental
Stock # / Date Outlines of Coverage and Summaries of Benefits Texas Form #
42339.0113 SelecTEMP PPO Outline of Coverage  PPO-STM-3-OLC-3
725624.0813 SelecTEMP PPO Outline of Coverage (Spanish Version)  PPO-STM-3-OLC-3-SP
57843.0114 Blue Choice Bronze PPO 005  TX-I-P-BC-OOC-BR-005FR
57844.0114 Blue Choice Bronze PPO 006  TX-I-P-BC-OOC-BR-006FR
57836.0114 Blue Choice Gold PPO 001  TX-I-P-BC-EX-OOC-GD-001FR
57837.0114 Blue Choice Gold PPO 002  TX-I-P-BC-EX-OOC-GD-002FR
57838.0114 Blue Choice Gold PPO 011  TX-I-P-BC-OOC-GD-011FR
57841.0114 Blue Choice Silver PPO 003  TX-I-P-BC-OOC-SL-003FR
57842.0114 Blue Choice Silver PPO 004  TX-I-P-BC-OOC-SL-004FR
N/A Blue Advantage Bronze HMO 005  TX-I-H-BA-BR-005-BH-Rev
N/A Blue Advantage Bronze HMO 006  TX-I-H-BA-BR-006-BH-Rev
N/A Blue Advantage Gold HMO 001  TX-I-H-BA-GD-001-BH-Rev
N/A Blue Advantage Gold HMO 002  TX-I-H-BA-GD-002-BH-Rev
N/A Blue Advantage Gold HMO 007  TX-I-H-BA-GD-007-BH-Rev
N/A Blue Advantage Gold HMO 008  TX-I-H-BA-GD-008-BH-NCC-Rev
N/A Blue Advantage Silver HMO 003  TX-I-H-BA-SL-003-BH-Rev
N/A Blue Advantage Silver HMO 004  TX-I-H-BA-SL-004-BH-Rev
57840.0114 Blue Security Choice PPO 010  TX-I-P-BC-OOC-CA-010FR
Stock # / Date Miscellaneous Forms Texas Form #
51436.0414 Automatic Premium Payment Authorization Agreement  N/A
726665.0514 Automatic Premium Payment Authorization Agreement (Spanish Version)  N/A
51178.0913 List Bill Agreement  N/A
Stock # / Date Other Benefit/Plan Information Texas Form #
57441.0214 Sales Brochure  N/A
725872.0214 Sales Brochure (Spanish Version)  N/A
46086.0113 SelecTEMP PPO Flier  N/A
725620.1013 SelecTEMP PPO Flier (Spanish Version)  N/A
57898.1013 Gold Plan Comparison Chart (Off Exchange)  N/A
57901.0613 Gold Plan Comparison Chart (On Exchange)  N/A
57897.0613 Silver Plan Comparison Chart (Off Exchange)  N/A
57900.0613 Silver Plan Comparison Chart (On Exchange)  N/A
57896.0613 Bronze Plan Comparison Chart (Off Exchange)  N/A
57899.0613 Bronze Plan Comparison Chart (On Exchange)  N/A
57905.1013 Combined Gold, Silver, Bronze Comparison Chart (Off Exchange) (Spanish Version)  N/A
726086.1013 Multi-State Plan (MSP) Comparison Chart (On Exchange)  N/A
726420.1213 Multi-State Plan (MSP) Comparison Chart (On Exchange) (Spanish Version)  N/A
Stock # / Date Dental Plan/Benefit Information Texas Form #
725568.1213 BlueCare Dental Flier  N/A
726267.1113 BlueCare Dental Flier (Spanish Version)  N/A
57825.0114 BlueCare Dental 4 Kids 1A  TX-I-D-OOC-96
57826.0114 BlueCare Dental 4 Kids 1B  TX-I-D-OOC-97
57882.0114 BlueCare Dental 1A  TX-I-D-OOC-01
57823.0114 BlueCare Dental 2A  TX-I-D-OOC-02
57824.0114 BlueCare Dental 1B  TX-I-D-OOC-03

Pre-2014 and Pre-ACA Individual Forms and Documents
Stock # / Date Enrollment Forms and Change Forms Texas Form #
41745.0111 Series V Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Saver)  IND-APP/MCF-3REV
41745.0111 Series V Application/Miscellaneous Change Form (PPO Select Blue Advantage/PPO Select Choice/PPO Select Saver) - Spanish Version  IND-APP/MCF-3REV SP
42352.0111 Series V Special Offer Application (PPO Select Blue Advantage/PPO Select Choice/PPO Select Saver)  This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application
IND-APP(SO)-2REV
51164.0111 BlueEdge Individual HSA Application/Miscellaneous Change Form 
BLUE EDGE IND-HSA-APP/MCF-5REV
51165.0111 BlueEdge Individual HSA Special Offer Application  This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application. BLUE EDGE-IND-HSA-APP(SO)-3REV
42780.0812 SelecTEMP PPO Temporary Individual Coverage Application  PPO-STM-3-APP-3
42320.0111 Foundation Hospital Care Miscellaneous Change Form  PPO-INHOSPITAL-APP/MCF-2REV
42684.0111 PPO Select Value Care Miscellaneous Change Form  PPO-IND-VALUE-APP/MCF-3REV
41694.0111 PPO Select Basic Miscellaneous Change Form 
PPO-IND-CCHBP-MCF(B)-4REV
43954.0111 MSA Blue Application/Miscellaneous Change Form  IND-CMM-APP/MCF-3REV
43971.0111 Non-Underwritten Changes Miscellaneous Change Form  This form is to be used for effective dates of December 1, 2007 and forward. It replaces the Miscellaneous Change Forms for older Select Products (i.e., PPO Select, PPO Select Advantage and Select 2000) and non-Series III, IV, and V Products (i.e., PPO Select Saver, PPO Select Choice and Select Blue Advantage). Use this form if you want to add dependent(s), cancel coverage or downgrade your benefits. IND-MCF-Non-UW-3
43969.0111 Underwritten Changes Miscellaneous Change Form  This form is to be used for effective dates of December 1, 2007 and forward. It replaces the Miscellaneous Change Forms for older Select Products (i.e., PPO Select, PPO Select Advantage, Select 2000) and non Series III, IV, and V Products (i.e., PPO Select Saver, PPO Select Choice and Select Blue Advantage). Use this form if you want to add dependent(s) or upgrade your benefits. IND-MCF-UW-3REV
Stock # / Date Outlines of Coverage and Patient Protection Act Disclosure Statements Texas Form #
55227.0713 PPO Select Choice Outline of Coverage (Series V)  PPO-SELCHOICE-5-OLC-1
55247.0412 SP PPO Select Choice Outline of Coverage (Series V) - Spanish Version  PPO-SELCHOICE-5-OLC-1 SP
55228.0412 PPO Select Choice Patient Protection Act Disclosure Statement (Series V)  PPO-SELCHOICE-5-DS-1
55231.0713 PPO Select Saver Outline of Coverage (Series V)  PPO-SELSAVER-5-OLC-1
55231.0412 SP PPO Select Saver Outline of Coverage (Series V) - Spanish Version  PPO-SELSAVER-5-OLC-1 SP
55232.0412 PPO Select Saver Patient Protection Act Disclosure Statement (Series V)  PPO-SELSAVER-5-DS-1
55235.0713 Select Blue Advantage Outline of Coverage (Series V)  PPO-SELBLUE-ADV-5-OLC-1
55235.0412 SP Select Blue Advantage Outline of Coverage (Series V) - Spanish Version  PPO-SELBLUE-ADV-5-OLC-1 SP
55236.0412 Select Blue Advantage Patient Protection Act Disclosure Statement (Series V)  PPO-SELBLUE-ADV-5-DS-1
55239.0713 BlueEdge Individual HSA Outline of Coverage  PPO-BLUEEDGE-INDL-HSA-3-OLC-2
55239.0412 SP BlueEdge Individual HSA Outline of Coverage - Spanish Version  PPO-BLUEEDGE-INDL-HSA-3-OLC-1 SP
55240.0412 BlueEdge Individual HSA Patient Protection Act Disclosure Statement  PPO-BLUEEDGE-INDL-HSA-3-DS-1
42339.0113 SelecTEMP PPO Outline of Coverage  PPO-STM-3-OLC-3
42340.0110 SelecTEMP PPO Patient Protection Act Disclosure Statement  PPO-STM-3-PPA-1
54504.0911 Blue Pathway Outline of Coverage  BLUE PATHWAY-OLC-1
Stock # / Date Claim Forms and Order Forms Texas Form #
40959.0113 Prescription Drug Claim Form  Members with pharmacy benefits through an individual insurance plan can use this form to request reimbursement for a prescription drug purchase. The original pharmacy receipt must be submitted with the completed form to Prime Therapeutics, the pharmacy benefits manager. 3272TXIND
1081.000.901 Medical Claim Form 
Members should use this form to request reimbursement of health services not already filed by their doctor or hospital.
N/A
1081.000.901 SP Medical Claim Form - Spanish Version 
Members should use this form to request reimbursement of health services not already filed by their doctor or hospital.
N/A
N-12-420 BlueCard Worldwide® International Claim Form 
Members should use this form to request reimbursement for out-of-network services received when traveling internationally (outside of U.S.).
N/A
N/A PrimeMail New Prescription Order Form  Members with prescription drug coverage can use this form to mail order new prescription maintenance medication. Mail the completed form to PrimeMail and include the original prescription signed by the prescribing doctor. 3208TXNEW.1210
N/A PrimeMail Refill Prescription Order Form  Members with prescription drug coverage can use this form to mail order refills for prescribed maintenance medication. 3208TXREFILL.1210
Stock # / Date Miscellaneous Forms Texas Form #
51436.0711 Automatic Premium Payment Authorization Agreement  - This form is to be used for pre-ACA plans only. N/A
49218.0409 Automatic Premium Payment Authorization Agreement - Spanish Version  - This form is to be used for pre-ACA plans only. N/A
47133.0109 Continuation of Coverage Request Form  N/A
51178.0109 List Bill Agreement  N/A
N/A Standard Authorization Form and other HIPAA Privacy Forms N/A
Stock # / Date Dental Plan Information Texas Form #
40110.404 Dental Indemnity USA Monthly Premium Rate Guide  N/A
0009.374-0908 Dental Indemnity USA Outline of Coverage  IND-DEN-2-OLC-1
N/A Dental Scheduled Benefit Plan - Region II  TXGRGNII
N/A Dental Scheduled Benefit Plan - Region IV  TXGRGNIV
Stock # / Date Other Plan Information Texas Form #
53398.0312 Blue Pathway Sales Flier  N/A
43378.0413 Plan Comparison Chart  N/A
56545.0113 Plan Comparison Chart - Spanish Version  N/A
50400.0113 Product Guide Brochure  N/A
54537.0113 Product Guide Brochure - Spanish Version  N/A
46086.0113 SelecTEMP PPO Flier  N/A
 

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