Forms and Translated Materials

Blue Cross Medicare Advantage
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Appointment of Representative
Authorization to Disclose Protected Health Information
Automated Premium Payment (ACH) Form
Prescription Drug Mail-Order Form
Prescription Drug Claim Form - HMO
Prescription Drug Claim Form - HMO-POS
Prescription Drug Claim Form - PPO
Prior Authorization
Request for Medicare Prescription Drug Coverage Determination Form
Request for Redetermination of Medicare Prescription Drug Denial Form
Physician Fax Form
File a Grievance    Please select your health plan and health plan type for information about filing a grievance.
Step Therapy Form — HMO
Step Therapy Form — HMO-POS
Step Therapy Form — PPO

en Español

Alternate formats for these materials, including Spanish translations, may be available. Please contact our Product Specialists for additional information.

Este material está disponible en otros formatos, incluida la traducción al Español. Contacte nuestro numero de Servicio al Cliente para obtener información adicional.

Materials in English - 2014 Materiales en Español - 2014
Summary of Benefits - HMO  
H3979_BEN_OK_MAPDSB14 Accepted 10012013
Summary of Benefits en Español- HMO  
H3979_BEN_OK_MAPDSB14SPA Accepted 10012013
Summary of Benefits - PPO  
H8634_BEN_OK_MAPDSB14 Accepted 10012013
Summary of Benefits en Español- PPO  
H8634_BEN_OK_MAPDSB14SPA Accepted 10012013
Drug List - HMO  
H3979_MRK_TMP_MAFRMLRY14 Accepted 10012013
Drug list - HMO en Español 
Y0096_MRK_TMP_MAFRMLRY14SPA_OK_HMO
Drug List - PPO  
H8634_MRK_TMP_MAFRMLRY14 Accepted 10012013
Drug list - PPO en Español 
Y0096_MRK_TMP_MAFRMLRY14SPA_OK_PPO
Pharmacy Directory  
H3979_BEN_TMP_MAPHAR14 Accepted 10012013
Pharmacy Directory en Español
Y0096_BEN_TMP_MAPHAR14SPA Accepted 10012013
Evidence of Coverage - HMO
[H3979]_BEN_OK_HMOEOC2014 Accepted 09062013
Evidence of Coverage - HMO en Español
H3979_BEN_TMP_MAEOCCVR14SPA Approved 08222013
Evidence of Coverage - HMO-POS
[H3979]_BEN_OK_HMOPOSEOC2014 Accepted 09062013
Evidence of Coverage - HMO-POS en Español
H3979_BEN_TMP_MAEOCCVR14SPA Approved 08222013
Evidence of Coverage - PPO
H8634_BEN_OK_PPOEOC2014 Accepted 09062013
Evidence of Coverage - PPO en Español
H8634_BEN_TMP_MAEOCCVR14 Approved 08192013