RETIREE PLANS
Forms and Documents
Find the forms you need to help you manage your Group Retiree Medicare plan.
Forms and Documents
Log in to Blue Access for Members℠ to view your plan documents. This secure, online site and mobile app provides you easy access to view your health benefit information from anywhere.
To download the app, text BCBSILAPP to 33633 or search for BCBSIL in the Apple App Store or in Google Play . (Message and date rates may apply.)
If you have questions about your plan documents, call the number listed on your BCBSIL member ID card.
General Plan Information
Prescription Drug Information
- Mail-Order Physician New Prescription Fax Form
- Medicare Part B vs. Part D Form
- Medicare Prescription Payment Plan Enrollment Form (MAPD)
- Medicare Prescription Payment Plan Enrollment Form (PDP)
- Prescription Drug Claim Form
- Prescription Drug Coverage Determination Request Form (MAPD)
- Prescription Drug Coverage Redetermination Request Form (MAPD)
- Prescription Drug Formulary Exception Physician Form
- Prescription Drug Tier Exception Physician Form
Other
- Access Additional Privacy Forms
- Authorization to Disclose Protected Health Information (PHI) Form
- Late Enrollment Penalty (LEP) Appeals
- Notice of Privacy Practices
If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form or contact the Office of the Medicare Ombudsman .
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