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 Advantage^SM Plans Documents

Blue Cross MedicareRx (PDP)^SM Plan Documents

Blue Medicare Supplement Insurance^SM Plan Documents

Blue Cross Medicare Advantage Dual Care Plus (HMO SNP)^SM Plan Documents

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 Pharmacy Mail-Order 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

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.