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
2021 Personal Medication List (PDP) English | español
2021 Personal Medication List (MAPD) English | español
2021 Personal Medication List (DSNP) English | español
2021 Online Coverage Determination Request Form
2021 Online Coverage Redetermination Request Form
2021 Mail-Order Physician New Prescription Fax Form
2021 Prescription Drug Claim Form
2021 Medicare Part B vs. Part D Form
2021 Authorization to Disclose Protected Health Information (PHI) Form
2021 CMS Appointment of Representative Form (PDP)
2021 CMS Appointment of Representative Form (MAPD)
2021 CMS Appointment of Representative Form (DSNP)
2021 Notice of Privacy Practices
2021 Access Additional Privacy Forms
2021 Automated Premium Payment (ACH) Form (PDP)
2021 Automated Premium Payment (ACH) Form (MAPD)
2021 Automated Premium Payment (ACH) Form (DSNP)
2021 Prescription Drug Coverage Determination Request Form (PDP) English | español
2021 Prescription Drug Coverage Redetermination Request Form (PDP) English | español
2021 Prescription Drug Coverage Determination Request Form (PPO) English | español
2021 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2021 Prescription Drug Coverage Determination Request Form (HMO) English | español
2021 Prescription Drug Coverage Redetermination Request Form (HMO) English | español
2021 Prescription Drug Coverage Determination Request Form (DSNP) English | español
2021 Prescription Drug Coverage Redetermination Request Form (DSNP) English | español
2021 Prescription Drug Formulary Exception Physician Form
2021 Prescription Drug Tier Exception Physician Form
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 Online Coverage Determination Request Form
2022 Online Coverage Redetermination Request Form
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 (DSNP) English | español
2022 Prescription Drug Coverage Redetermination Request Form (DSNP) English | español
2022 Prescription Drug Formulary Exception Physician Form
2022 Prescription Drug Tier Exception Physician Form
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: 09302020
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