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 Insurancfe required Disclosure Notice  for all individual HMO Consumer Choice benefit plans issued in Texas.

Current Product Comparison Charts
Combined On and Off Exchange Comparison Charts (English) Combined On and Off Exchange Comparison Charts (Spanish)
Gold Plan Comparison Chart  Gold Plan Comparison Chart 
Silver Plan Comparison Chart  Silver Plan Comparison Chart 
Bronze Plan Comparison Chart  Bronze Plan Comparison Chart 
Multi-State Plan Comparison Chart  Multi-State Plan Comparison Chart 

 

Current Individual Forms and Documents
Stock # / Date Enrollment Forms and Change Forms Texas Form #
57330.1016 Health Application/Change in Coverage  Use this application for the 2017 plans, which are effective January 1, 2017. UN65-APP/OFF-EXG-2
57330.0216 Health Application/Change in Coverage  Use this application for the 2016 plans. UN65-APP/OFF-EXG-1
725600.1016 Health Application/Change in Coverage (Spanish Version) Use this application for 2017 plans, effective January 1, 2017. UN65-APP/OFF-EXG-SP-2
725600.1115 Health Application/Change in Coverage (Spanish Version)  Use this application for the 2016 plans. UN65-APP/Off-EXG-SP
57784.1016 Dental Application/Change in Coverage Use this dental application for 2017 plans, effective January 1, 2017. UN65-APP/DentalG-2
57784.0216 Dental Application/Change in Coverage  Use this application for the 2016 plans. UN65-APP/DentalG-1
725603.1016 Dental Application/Change in Coverage (Spanish Version)  Use this application for 2017 plans, effective January 1, 2017 UN65-APP/DentalG-SP-2
725603.1115 Dental Application/Change in Coverage (Spanish Version)  Use this application for the 2016 plans. UN65-APP/DentalG-SP
Stock # / Date Benefit Highlights Texas Form #
N/A Blue Advantage Bronze HMO 006  TX-I-H-CC-BH-17-R
N/A Blue Advantage Bronze HMO 105  TX-I-H-CC-BH-17-R
N/A Blue Advantage Gold HMO 101  TX-I-H-CC-BH-17-R
N/A Blue Advantage Gold HMO 111  TX-I-H-NCC-BH-17-R
N/A Blue Advantage Silver HMO 102  TX-I-H-CC-BH-17-R
N/A Blue Advantage Silver HMO 103  TX-I-H-CC-BH-17-R
N/A Blue Advantage Plus Gold 101  TX-I-H-CC-BH-17-R
N/A Blue Advantage Plus Silver 102  TX-I-H-CC-BH-17-R
N/A Blue Advantage Plus Bronze 103  TX-I-H-CC-BH-17-R
N/A Blue Advantage Plus Bronze 104  TX-I-H-CC-BH-17-R
N/A Blue Advantage Security HMO 100  TX-I-H-CC-BH-17-R
Stock # / Date Miscellaneous Forms Texas Form #
51436.0914 EZ Blue Payment Option Automatic Premium Payment Authorization Agreement  N/A
726665.0914 EZ Blue Payment Option Automatic Premium Payment Authorization Agreement (Spanish Version)  N/A
732049.0816 QHP List Bill – EZ Blue Payment Option Automatic Premium Payment Authorization Agreement  N/A
732309.0816 QHP List Bill Agreement  N/A
51178.0913 List Bill Agreement  N/A
N/A Custodial Parent Affidavit N/A
Stock # / Date Other Benefit/Plan Information Texas Form #
729761.0616 Sales Brochure  N/A
725872.0816 Sales Brochure (Spanish Version)  N/A
Stock # / Date Dental Plan/Benefit Information Texas Form #
725568.0816 BlueCare Dental Flier  N/A
726267.0816 BlueCare Dental Flier (Spanish Version)  N/A
57825.0117 BlueCare Dental 4 Kids 1A  TX-I-D-OOC-4K-1A-17
57826.0117 BlueCare Dental 4 Kids 1B  TX-I-D-OOC-4K-1B-17
57822.0117 BlueCare Dental 1A  TX-I-D-OOC-1A-17
57824.0117 BlueCare Dental 2A  TX-I-D-OOC-2A-17
57823.0117 BlueCare Dental 1B  TX-I-D-OOC-1B-17

 

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
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
54504.0911 Blue Pathway Outline of Coverage  BLUE PATHWAY-OLC-1
Stock # / Date Claim Forms and Order Forms Texas Form #
735026.0915 Medical Claim Form (Domestic) 
Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base.
N/A
731140.0116 Medical Claim Form (Domestic) – Spanish 
Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base.
N/A
N-12-420 Medical Claim Form (International) 
Members should use this BlueCard Worldwide claim form to request reimbursement for health care services obtained when traveling internationally - when outside of the United States or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base.
N/A
3272 TX
01/16
Prescription Drug Claim Form  Members with pharmacy benefits through BCBSTX 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. N/A
3208 TX
04/16
PrimeMail Order Form  Members with prescription drug coverage can use this form to mail order new or refill prescription maintenance medication. Mail the completed form to PrimeMail and include the original prescription signed by the prescribing doctor. N/A
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
08.01.15 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
 

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