This page may have documents that can’t be read by screen reader software. For help with these documents, please call 1-877-774-8592.
Forgot user name or password?
Find Medicare Advantage, prescription drug, Medicare Supplement and other forms you need to help you manage your Medicare plan.
Blue Cross Medicare AdvantageSM Plans Documents
Blue Cross MedicareRx (PDP)SM Plan Documents
Plan 65 Medicare Supplement Insurance Plan Documents
2020 Online Coverage Determination Request Form
2020 Online Coverage Redetermination Request Form
2020 Prescription Drug Coverage Determination Request Form (PDP)
2020 Prescription Drug Coverage Redetermination Request Form (PDP)
2020 Prescription Drug Coverage Determination Request Form (MAPD)
2020 Prescription Drug Coverage Redetermination Request Form (MAPD)
2020 Mail-Order Physician New Prescription Fax Form
2020 Pharmacy Mail-Order Form
2020 Prescription Drug Claim Form
2020 Medicare Part B vs. Part D Form
2020 Authorization to Disclose Protected Health Information (PHI) Form
2020 CMS Appointment of Representative Form
2020 Notice of Privacy Practices
2020 Access Additional Privacy Forms
2020 Automated Premium Payment (ACH) Form (PDP)
2020 Automated Premium Payment (ACH) Form (MAPD)
2020 Prescription Drug Formulary Exception Physician Form
2020 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: 12312019Y0096_WEBOKMM20