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 seeking a PPO plan 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.

Current Product Comparison Charts
Combined On and Off Exchange Comparison Charts (English) Combined On and Off Exchange Comparison Charts (Spanish)
2022 Gold Plan Comparison Chart 2022 Gold Plan Comparison Chart
2022 Silver Plan Comparison Chart 2022 Silver Plan Comparison Chart
2022 Bronze Plan Comparison Chart 2022 Bronze Plan Comparison Chart

 

Current Individual Forms and Documents

Stock # / Date Enrollment Forms and Change Forms Texas Form #
TBA 2022 Individual Paper Application Checklist N/A
TBA 2022 Individual Paper Application Checklist (Spanish Version) N/A
TBA Health Application/Change in Coverage Use this health application for 2022 plans, effective January 1, 2022. TBA
TBA Health Application/Change in Coverage (Spanish Version) Use this application for 2022 plans, effective January 1, 2022. TBA
TBA Dental Application/Change in Coverage Use this dental application for 2022 plans, effective January 1, 2022. TBA
TBA Dental Application/Change in Coverage (Spanish Version) Use this application for 2022 plans, effective January 1, 2022. TBA
TBA 2022 Individual Paper Application Overflow Page TBA
TBA 2022 Individual Paper Application Overflow Page (Spanish Version) TBA
Stock # / Date Benefit Highlights Forms Texas Form #
     
N/A Blue Advantage Gold HMO 206 TBA
N/A Blue Advantage Gold HMO 207 TBA
N/A Blue Advantage Silver HMO 306 TBA
N/A Blue Advantage Silver HMO 205 TBA
N/A Blue Advantage Bronze HMO 302 TBA
N/A Blue Advantage Bronze HMO 204 TBA
N/A Blue Advantage Bronze HMO 301 TBA
N/A Blue Advantage Security HMO 200 TBA
N/A Blue Advantage Plus Gold 203 TBA
N/A Blue Advantage Plus Silver 306 TBA
N/A Blue Advantage Plus Silver 202 TBA
N/A Blue Advantage Plus Bronze 201 TBA
N/A Blue Advantage Plus Bronze 303 TBA
N/A Blue Advantage Plus Bronze 305 TBA
N/A Blue Advantage Plus Bronze 501 TBA
N/A MyBlue Health Gold 403 TBA
N/A MyBlue Health Silver 405 TBA
N/A MyBlue Health Bronze 402 TBA
N/A Blue Advantage Plus Silver 605 TBA
N/A Blue Advantage Gold HMO 603 TBA
N/A Blue Advantage Silver HMO 601 TBA
Stock # / Date Miscellaneous Forms Texas Form #
51436.1018 Auto Bill Pay - Automatic Premium Payment Authorization Agreement N/A
726685.1018 Automatic Premium Payment Authorization Agreement (Spanish) N/A
N/A Custodial Parent Affidavit N/A
748937.0719 Disabled Dependent Authorization Form (for Individual Plans)
Members with an Individual health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSTX (see address and fax number at the top of the form).
N/A
747142.1018 Responsible Party Form TX-RPF-2018
Stock # / Date Other Benefit/Plan Information Texas Form #
TBA 2022 Sales Brochure N/A
TBA 2022 Sales Brochure (Spanish) N/A
Stock # / Date Dental Plan/Benefit Information Texas Form #
TBA 2022 Sales Brochure N/A
TBA 2022 Sales Brochure (Spanish) N/A
N/A BlueCare Dental 4 Kids 1A N/A
N/A BlueCare Dental 4 Kids 1B N/A
N/A BlueCare Dental 1A N/A
N/A BlueCare Dental 2A N/A
N/A BlueCare Dental 1B N/A
Stock # / Date Claim Forms and Order Forms Texas Form #
J430 Dental Claim Form
Members should use this form to file dental claims for reimbursement that are not filed by their dental provider.
N/A
730526.0915 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 N/A
16-581-N35 Medical Claim Form (International)
Members should use this 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
16-581-N35 Medical Claim Form (International) – Spanish N/A
3272 TX
03/18
Prescription Drug Claim Form (Prime Therapeutics) 
Members with pharmacy benefits through BCBSTX can use this form to request reimbursement for a prescription drug purchase. They must submit the original pharmacy receipt with the completed form.
N/A
3272 TX SP
03/18
Prescription Drug Claim Form (Prime Therapeutics) – Spanish N/A
EME47693 Prescription Drug Mail-Order Form (Express Scripts)
Members with prescription drug coverage can use Express Scripts Pharmacy to order new or refill prescription drugs for home delivery. They need to mail the completed form to the address provided on the form, and include the original prescription signed by their doctor.
N/A
EME47693 Prescription Drug Mail-Order Form (Express Scripts) – Spanish N/A

 

Pre-ACA Individual Forms and Documents

Stock # / Date Enrollment Forms and Change Forms Texas Form #
41745.0517 Series V Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Saver) IND-APP/MCF-4REV
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
733084.0117 Application for Transfer of Coverage
N/A
51164.0217 BlueEdge Individual HSA Application/Miscellaneous Change Form
BLUE EDGE-IND-HSA-APP/MCF-6REV
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 Miscellaneous Forms Texas Form #
752154.1119 Automatic Premium Payment Authorization Agreement - This form is to be used for pre-ACA plans only. 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