Member Forms

Search for a Blue Cross and Blue Shield of Montana form with our Form Finder tool. Or, use the list below.

• 2024 Individual Health Plan Application Checklist
  Use this checklist to make sure your 2024 application is complete and correct.
• 2024 Individual Health Plan Application/Change in Coverage (Off Exchange)
  Use this form to apply for a BCBSMT Individual Health Plan (Off Exchange) effective January 1, 2024, or to submit a change in coverage. For individuals under age 65.
• 2024 Individual Health Plan Application/Change in Coverage Additional Dependents Form
  If you run out of room on the primary application for health plan coverage, use this form to add more dependents to your policy. Use this form for plans effective January 1, 2024.
• 2024 Individual Dental Plan Application/Change in Coverage
  Use this form to apply for a BCBSMT Individual Dental Plan effective January 1, 2024, or to submit a change in coverage.
• 2024 Small Group Enrollment Application/Change Form
  
• Use this form to apply for small group coverage effective January 1, 2024.
• 2024 Large Group Enrollment Application/Change Form
  Use this form to apply for large group coverage effective January 1, 2024.
• Individual Plan Responsible Party Form (Child-Only Policy) 
  Please fill out this form if you have applied for a child-only policy but did not specify the policy owner. Use this form to tell BCBSMT that you will be the responsible party/policy owner for the child-only policy.
• Application for Medicare Supplement Insurance Plan
  Those who are eligible for Medicare can use this form to apply for BCBSMT insurance that will supplement their Medicare coverage.

• Claim Form – Dental
  Use this form to file dental claims for reimbursement that are not filed by your dental provider.
• Claim Form – Dental (Spanish)
• Claim Form – Medical (Domestic)
  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.
• Claim Form – Medical (International)
  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.
• Health Fair, Lab and Immunization Submission Form
  Use this form to submit preventative immunization or laboratory services received at a Heath Fair, a City/County Health Department, Pharmacy, etc. Include a receipt or itemized statement.

• Authorized Representative for Internal Appeal and External Review Form
  This form is to authorize a provider or other person to appeal a denial on your behalf. Member authorization is needed on all standard pre-service appeals and all claims that are member responsibility.
• Member Appeal Review Form
  This form is to submit a first level appeal (dispute) regarding an adverse benefit determination (denial).

• Prescription Drug Claim Form (Prime Therapeutics^®)
  Members with pharmacy benefits through BCBSMT: Use this claim form to request reimbursement after you buy a prescription drug or over-the-counter (OTC) COVID-19 home test kit. You must submit the pharmacy counter receipt with the completed form. Cash register receipts for OTC COVID-19 test kits may not be accepted. Not all plans cover OTC COVID-19 home test kits. If your plan does not cover, you will not be reimbursed.
• Prescription Drug Mail-Order Form (Express Scripts^®)
  Members with BCBSMT prescription drug coverage can use Express Scripts Pharmacy to order new or refill prescription drugs for home delivery. Mail the completed form to the address provided on the form, and include the original prescription signed by your doctor.
• Prescription Drug Mail-Order Form (Ridgeway)
  Members with BCBSMT prescription drug coverage can use Rideway Pharmacy to order prescription drugs for home delivery. Follow the instructions on the form.

• MUS Faculty/Staff Massage Therapy Claim Form
• MUST Immunization Submission Form 
• Marsh & McLennan Agency LLC Message Therapy Claim Form
• Ranch and Home Supply Massage Therapy Claim Form
• Bitterroot Health Out-of-Network Exception Request Form
• Bitterroot Health Vision Claim Form