Documents & Forms
We've put together the most common documents and forms you might need for things like filing claims or reviewing your coverage. Start by choosing what kind of insurance you have from the list below.
- Through Your Employer
- Individual & Family
- Medicare Advantage (BlueAdvantage)
- Medicare Advantage (BlueEssential)
- Medicare Supplement (BlueElite)
- Medicare with Medicaid (BlueCare Plus℠)
Use these resources to help you enroll in a plan. If you have a BlueCare Plus plan, you can ignore the “subsidy tables.” You won’t pay a monthly premium payment while you have this plan.
These documents contain information about your benefits, network and coverage.
Use these forms to file an appeal about coverage or payment decisions, or to file grievance if you have concerns about your plan, providers or quality of care.
These documents offer information about your covered drug benefits.
- Medicare with Medicaid (BlueCare Plus) Medication List (Formulary)
- Prescription Claim Form
- Request for Prescription Coverage Determination Form
- Request for Prescription Redetermination Form
- Prescription Home Delivery Form
- Part D Out of Network Coverage
- Prior Authorization Criteria
- Quality Assurance Policies and Procedures
- Transition Policies and Procedures
- Over-the-Counter Order Form
- One Touch® Free Blood Glucose Monitor Voucher
- Ascensia® Contour Free Blood Glucose Monitor Voucher
You'll find notices and forms in this section that will help you understand your rights and responsibilities, and make requests related to those rights.
Use these resources to help you get the care you need and stay well.