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)|
|2023 Gold Plan Comparison Chart||2023 Gold Plan Comparison Chart|
|2023 Silver Plan Comparison Chart||2023 Silver Plan Comparison Chart|
|2023 Bronze Plan Comparison Chart||2023 Bronze Plan Comparison Chart|
Current Individual Forms and Documents
|Stock # / Date||Enrollment Forms and Change Forms||Texas Form #|
|745718.1022||2023 Individual Paper Application Checklist||N/A|
|746129.1122||2023 Individual Paper Application Checklist (Spanish Version)||N/A|
|57330.1022||2023 Health Application/Change in Coverage
Use this health application for 2023 plans effective January 1, 2023.
|725600.1122||2023 Health Application/Change in Coverage (Spanish Version)||UN65-APP-Off-EX-2023SP|
|57784.1022||2023 Dental Application/Change in Coverage
Use this dental application for 2023 plans effective January 1, 2023.
|725603.1122||2023 Dental Application/Change in Coverage (Spanish Version)||APP-DENT-IND-2023SP|
|727791.1022||2023 Individual Paper Application Overflow Page||UN65-APP-Off-EX-2023-O|
|727808.1122||2023 Individual Paper Application Overflow Page (Spanish Version)||UN65-APP-Off-EX-2023SP-O|
|Stock # / Date||Benefit Highlights Forms||Texas Form #|
|N/A||Blue Advantage Gold HMO 206||TBA|
|N/A||Blue Advantage Bronze HMO 301||TBA|
|N/A||Blue Advantage Bronze HMO 302||TBA|
|N/A||Blue Advantage Bronze HMO 702||TBA|
|N/A||Blue Advantage Bronze HMO 704||TBA|
|N/A||Blue Advantage Bronze HMO 707||TBA|
|N/A||Blue Advantage Gold HMO 206||TBA|
|N/A||Blue Advantage Gold HMO 207||TBA|
|N/A||Blue Advantage Gold HMO 603||TBA|
|N/A||Blue Advantage Gold HMO 706||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||Blue Advantage Plus Bronze 704||TBA|
|N/A||Blue Advantage Plus Bronze 707||TBA|
|N/A||Blue Advantage Plus Gold 203||TBA|
|N/A||Blue Advantage Plus Gold 706||TBA|
|N/A||Blue Advantage Plus Silver 202||TBA|
|N/A||Blue Advantage Plus Silver 306||TBA|
|N/A||Blue Advantage Plus Silver 605||TBA|
|N/A||Blue Advantage Plus Silver 705||TBA|
|N/A||Blue Advantage Security HMO 200||TBA|
|N/A||Blue Advantage Silver HMO 205||TBA|
|N/A||Blue Advantage Silver HMO 306||TBA|
|N/A||Blue Advantage Silver HMO 601||TBA|
|N/A||Blue Advantage Silver HMO 705||TBA|
|N/A||MyBlue Health Bronze 402||TBA|
|N/A||MyBlue Health Gold 403||TBA|
|N/A||MyBlue Health Silver 405||TBA|
|Stock # / Date||Miscellaneous Forms||Texas Form #|
|51436.0222||Auto Bill Pay - Automatic Premium Payment Authorization Agreement||N/A|
|726685.1018||Auto Bill Pay - Automatic Premium Payment Authorization Agreement (Spanish)||N/A|
|N/A||Custodial Parent Affidavit||N/A|
|748937.0622||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).
|747142.1018||Responsible Party Form||TX-RPF-2018|
|Stock # / Date||Other Benefit/Plan Information||Texas Form #|
|729761.0922||2023 Sales Brochure||N/A|
|725872.0922||2023 Sales Brochure (Spanish)||N/A|
|Stock # / Date||Dental Plan/Benefit Information||Texas Form #|
|TBA||2023 Dental Brochure||N/A|
|TBA||2023 Dental Brochure (Spanish)||N/A|
|TBA||BlueCare Dental 4 Kids 1A||N/A|
|TBA||BlueCare Dental 4 Kids 1B||N/A|
|TBA||BlueCare Dental 1A||N/A|
|TBA||BlueCare Dental 1B||N/A|
|TBA||BlueCare Dental 1C||N/A|
|TBA||BlueCare Dental 2A||N/A|
|Stock # / Date||Claim Forms and Order Forms||Texas Form #|
|758995.0522||Dental Claim Form
Members should use this form to file dental claims for reimbursement that are not filed by their dental provider.
|55353.0413||Dental Claim Form – Spanish||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.
|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.
|16-581-N35||Medical Claim Form (International) – Spanish||N/A|
|Prescription Drug Claim Form (Prime Therapeutics)
Members with pharmacy benefits through BCBSTX can use this Prime Therapeutics claim form to request reimbursement for purchasing a prescription drug or over-the-counter (OTC) COVID-19 diagnostic home test kit. For prescription drugs, you must submit the original pharmacy receipt with the completed form. For COVID-19 home test kits, you must submit the original cash register or online receipt with the completed form.
|3272 TX SP
|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.
|EME47693||Prescription Drug Mail-Order Form (Express Scripts) – Spanish||N/A|