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Find Medicare Advantage, Medicare Supplement and other forms you need to help you manage your Medicare plan.
Blue Cross Medicare AdvantageSM Plan Documents
Simply BlueSM Medicare Supplement Insurance Plan Documents
2022 Personal Medication List English | español
2022 Prescription Drug Coverage Determination Request Form (PPO) English | español
2022 Online Coverage Determination Request Form
2022 Prescription Drug Coverage Redetermination Request Form (PPO) English | español
2022 Online Coverage Redetermination Request Form
2022 Mail-Order Physician New Prescription Fax Form
2022 Pharmacy Mail-Order Form
2022 Prescription Drug Claim Form
2021 Medicare Part B vs. Part D Form
2022 Authorization to Disclose Protected Health Information (PHI) Form
2022 Automated Premium Payment (ACH) Form (MAPD)
2022 CMS Appointment of Representative Form
2022 Notice of Privacy Practices
2022 Access Additional Privacy Forms
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.
Last Updated: 09302021