Forms and Documents

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

• Automated Premium Payment (ACH) Form (MAPD)
• Automated Premium Payment (ACH) Form (PDP)
• CMS Appointment of Representative Form (MAPD)
• CMS Appointment of Representative Form (PDP)

Prescription Drug Information

• Mail-Order Physician New Prescription Fax Form
• Medicare Part B vs. Part D Form
• Online Coverage Determination Request Form
• Online Coverage Redetermination Request Form
• Personal Medication List
• Pharmacy Mail-Order Form
• Prescription Drug Claim Form
• Prescription Drug Coverage Determination Request Form (MAPD)
• Prescription Drug Coverage Determination Request Form (PDP)
• Prescription Drug Coverage Redetermination Request Form (MAPD)
• Prescription Drug Coverage Redetermination Request Form (PDP)
• 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.