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℠)
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.
- Prior Authorization Criteria
- Essential Medication List (Formulary)
- Essential Plus Medication List (Formulary)
- Preferred Medication List (Formulary)
- Prescription Claim Form
- Prescription Exception Request Form
- Specialty Pharmacy Network List
- Provider-Administered Specialty Drug List
- Over the Counter Savings Drug List
- ACA Preventive Drug List
- BlueCross Preventive Drug List
- Rules for When We Cover Opioids
- Prescription Home Delivery Form
- One Touch® Free Blood Glucose Monitor Voucher
- Ascensia® Contour 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)
-
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
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.
- Essential Medication List (Formulary)
- Essential Plus Medication List (Formulary)
- Preferred Medication List (Formulary)
- Prescription Claim Form
- Prescription Exception Request Form
- Specialty Pharmacy Network List
- Provider-Administered Specialty Drug List
- Over the Counter Savings Drug List
- ACA Preventive Drug List
- BlueCross Preventive Drug List
- Prescription Home Delivery Form
- Rules for When We Cover Opioids
- One Touch® Free Blood Glucose Monitor Voucher
- Ascensia® Contour 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)
-
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