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 Supplement (BlueElite)
- Medicare with Medicaid (BlueCare Plus℠)
Through Your Employer
Use these forms if you'd like to submit a claim.
These documents contain information about your benefits, network and coverage.
These documents offer information about your covered drug benefits.
- 2025 Essential Medication List (Formulary)
- 2025 Essential Plus Medication List (Formulary)
- 2025 Preferred Medication List (Formulary)
- 2025 BlueCross Preferred Preventive Drug List
- 2025 Choice Medication List (Formulary)
- 2025 Control Medication List (Formulary)
- 2025 Control and Choice Preventive Drug List
- Prescription Exception Request Form
- Preferred Specialty Pharmacy Network List
- Exclusive Specialty Pharmacy Network
- Provider-Administered Specialty Drug List
- Provider-Administered Specialty Medication Step Therapy Guide
- Medical Exclusions Medication List
- Over the Counter Savings Drug List
- ACA $0 Copay Drugs & Contraceptives List
- Rules for When We Cover Opioids
- Prescription Mail Service Order Form
- One Touch® Free Blood Glucose Monitor Voucher
These documents offer information about your health accounts and financial arrangements.
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.
-
Notice of Privacy Practices
-
Request to View Records
- Request to View Records (Spanish)
-
Request to Amend Records
- Request to Amend Records (Spanish)
-
Request to Disclose Records
- Request to Disclose Records (Spanish)
-
Request Alternative or Confidential Communication
-
Request to See Information Disclosures
-
Request Personal Representative
- Request Personal Representative (Spanish)
- Grievance Form
- Grievance Form (Spanish)
- ERISA Disclosure Request
- ERISA Disclosure Request (Spanish)
-
Privacy Complaint
- Privacy Complaint (Spanish)
-
Request to Restrict Our Use or Disclosure of Health
Information
- Request to Restrict Our Use or Disclosure of Health Information (Spanish)
- Request Interpreter Services in Another Language
- Subrogation Questionnaire
- Subrogation FAQs
- Surprise Billing Patient Disclosure Notice
Individual & Family
Use these forms if you'd like to submit a claim.
Use these forms if you'd like BlueCross to accept bank draft payments.
These documents contain information about your benefits, network and coverage.
These documents offer information about your covered drug benefits.
- Prior Authorization Criteria
- 2025 Essential Medication List (Formulary)
- 2025 Essential Plus Medication List (Formulary)
- Prescription Exception Request Form
- Preferred Specialty Pharmacy Network List
- Exclusive Specialty Pharmacy Network
- Provider-Administered Specialty Drug List
- Provider-Administered Specialty Medication Step Therapy Guide
- Medical Exclusions Medication List
- Over the Counter Savings Drug List
- ACA $0 Copay Drugs & Contraceptives List
- Prescription Mail Service Order Form
- Rules for When We Cover Opioids
- One Touch® Free Blood Glucose Monitor Voucher
These documents offer information about your health accounts and financial arrangements.
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.
-
Notice of Privacy Practices
-
Request to View Records
- Request to View Records (Spanish)
-
Request to Amend Records
- Request to Amend Records (Spanish)
-
Request to Disclose Records
- Request to Disclose Records (Spanish)
-
Request Alternative or Confidential Communication
-
Request to See Information Disclosures
-
Request Personal Representative
- Request Personal Representative (Spanish)
- Grievance Form
- Grievance Form (Spanish)
- ERISA Disclosure Request
- ERISA Disclosure Request (Spanish)
-
Privacy Complaint
- Privacy Complaint (Spanish)
-
Request to Restrict Our Use or Disclosure of Health
Information
- Request to Restrict Our Use or Disclosure of Health Information (Spanish)
- Request Interpreter Services in Another Language
- Subrogation Questionnaire
- Subrogation FAQs
- Surprise Billing Patient Disclosure Notice