Forms and Documents
Find Medicare Advantage Plan, Medicare Advantage Dual Care Plan (HMO SNP), Prescription Drug Plan and Medicare Supplement Insurance Plan forms and documents 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 Plan Documents
Blue Cross Medicare Advantage Dual Care Plus (HMO SNP)SM Plan Documents
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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 (DSNP)
- CMS Appointment of Representative Form (MAPD)
- CMS Appointment of Representative Form (PDP)
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
- Blue Cross Medicare Advantage Dual Care (HMO SNP) Program Summary
- 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 (DSNP)
- CMS Appointment of Representative Form (MAPD)
- CMS Appointment of Representative Form (PDP)
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
- Blue Cross Medicare Advantage Dual Care (HMO SNP) Program Summary
- 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.
Last Updated: 03222024
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