Forms and Documents
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
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General Plan Information
Prescription Drug Information
- Mail-Order Physician New Prescription Fax Form
- Medicare Part B vs. Part D Form
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List
- Pharmacy Mail-Order Form
- Prescription Drug Claim Form
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form (PPO)
- Prescription Drug Formulary Exception Physician Form
- Prescription Drug Tier Exception Physician Form
Other
- Access Additional Privacy Forms
- Authorization to Disclose Protected Health Information (PHI) Form
- Automated Premium Payment (ACH) Form (MAPD)
- Late Enrollment Penalty (LEP) Appeals
- Notice of Privacy Practices
If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form or contact the Office of the Medicare Ombudsman.
General Plan Information
Prescription Drug Information
- Mail-Order Physician New Prescription Fax Form
- Medicare Part B vs. Part D Form
- Online Coverage Determination Request Form
- Online Coverage Redetermination Request Form
- Personal Medication List
- Pharmacy Mail-Order Form
- Prescription Drug Claim Form
- Prescription Drug Coverage Determination Request Form (PPO)
- Prescription Drug Coverage Redetermination Request Form (PPO)
- Prescription Drug Formulary Exception Physician Form
- Prescription Drug Tier Exception Physician Form
Other
- Access Additional Privacy Forms
- Authorization to Disclose Protected Health Information (PHI) Form
- Automated Premium Payment (ACH) Form (MAPD)
- Late Enrollment Penalty (LEP) Appeals
- Notice of Privacy Practices
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: Jan. 01, 2023
Last Updated: 09302022
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