Forms and Documents

Find Medicare Advantage, Medicare Supplement and other forms you need to help you manage your Medicare plan.

Blue Cross Medicare Advantage^SM Plan Documents

Simply Blue^SM 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.