Medicare Forms

HIPAA Notice of Privacy Practice 

Your Member Rights and More (Part C HMO plans) (PDF)

Late Enrollment Penalty (LEP) Appeals

Medicare beneficiaries may incur a late enrollment penalty (LEP) if there is a continuous period of 63 days or more at any time after the end of the individual's Part D initial enrollment period during which the individual was eligible to enroll but was not enrolled in a Medicare Part D plan and was not covered under any creditable prescription drug coverage.

Information about LEP

Information about LEP appeals

LEP Appeal Form

Medicare Advantage (Part C): Appeals & Grievances

You have the right to file a grievance or submit an appeal and ask us to review your coverage determination.

How to file an Appeal or Grievance

Appeals & Grievances Form

Rights and Responsibilities upon Disenrollment: You have the right to ask us to reconsider this decision. You can ask us to reconsider by filing a grievance with us. You can look in your “Evidence of Coverage” for information about how to file a grievance, contact us at 1-800-926-6565 (TTY users: 1-800-955-8770) or click here for more information. Upon request, Medicare Advantage plans are required to disclose grievance and appeals data to Medicare Advantage enrollees in accordance with the regulatory requirements. You can contact us at 1-800-926-6565 (TTY users: 1-800-955-8770) to request this information.

Prescription Drug (Part D): Appeals & Grievances

You have the right to file a grievance or submit an appeal and ask us to review your coverage determination.

How to file an Appeal or Grievance

Coverage Determination Form

Coverage Redetermination Form

Rights and Responsibilities upon Disenrollment: You have the right to ask us to reconsider this decision. You can ask us to reconsider by filing a grievance with us. You can look in your “Evidence of Coverage” for information about how to file a grievance, contact us at 1-800-926-6565 (TTY users: 1-800-955-8770) or click here for more information. Upon request, Prescription Drug plans are required to disclose grievance and appeals data to Prescription Drug enrollees in accordance with the regulatory requirements. You can contact us at 1-800-926-6565 (TTY users: 1-800-955-8770) to request this information.

Appoint a Representative

You can appoint someone to act on your behalf. Go to Medicare.gov to download a form to Appointment of Representative. Go to Medicare.gov

Send a complaint to Medicare

You can file a complaint about your Medicare health or drug plan. Go to Medicare.gov to file a Medicare Complaint Form. Go to Medicare.gov

Find forms and documents to help you manage your plan.

• Summary of Benefits
• Annual Notice of Change
• Evidence of Coverage
• Formulary
• Enrollment Form
• Medicare Star Rating
• Prescription Drug Transition Policy
• LIS Premium Summary Chart
• Medicare Advantage plans

  • BlueMedicare Choice (Regional PPO)

  • BlueMedicare Classic (HMO)

  • BlueMedicare Classic Plus (HMO)

  • BlueMedicare Complete (HMO D-SNP)

  • BlueMedicare Patriot (PPO)

  • BlueMedicare Premier (HMO)

  • BlueMedicare Saver (HMO)

  • BlueMedicare Select (PPO)

  • BlueMedicare Value (PPO)

Your Member Rights

• Your Member Rights and More (Part C HMO plans) (PDF)

Prior Authorization Request

• Prior Authorization Request (PDF)

Automatic Payment

• Automatic Payment Form - Medicare Advantage (PDF)

Claims

• Pharmacy Claim Form (PDF)
• Medical Claim Form (for medical services in the U.S., including cruise ships departing the U.S.) (PDF)
• Medical Claims Form BCBS Global Core (PDF)

Medication Therapy Management Program (MTM)

• Visit the MTM Program page for Florida Blue members enrolled in Medicare Advantage HMO, LPPO and RPPO (Part C) plans. 

Find forms and documents to help you manage your plan.

• Summary of Benefits
• Annual Notice of Change
• Evidence of Coverage
• Formulary
• Enrollment Form
• Medicare Star Rating
• Prescription Drug Transition Policy
• LIS Premium Summary Chart
• Medicare Prescription Drug plans
  • BlueMedicare Complete Rx
  • BlueMedicare Premier Rx

Prime Therapeutics

• Visit MyPrime.com to find prescription drug forms and information, such as claim forms and formularies. You will be asked a few questions so the site can determine which set of forms to show you.
• 2023 Prior Authorization Criteria  (PDF)
• 2023 Step Therapy (PDF)

Automatic Payment

• Automatic Payment Form - Prescription Drug Plans (PDF)

Claims

• Pharmacy Claim Form (PDF)

Medication Therapy Management Program (MTM)

• Visit the MTM Program page for Florida Blue members enrolled in stand-alone Medicare Prescription Drug (Part D) plans. 

If your prescription drug coverage is not from Florida Blue Medicare (through our pharmacy benefits manager, Prime Therapeutics), please contact your pharmacy benefits administrator for the forms you need.

Find forms and documents to help you manage your plan.

Automated Payment Form - Medicare Supplement (PDF)

Take advantage of convenience security and savings with our Automatic Payment Option.

• Outline of Coverage Florida Blue Medicare Supplement Plans A, B, C, D, F, G, K, L, M, N (PDF)
• Outline of Coverage Florida Blue Medicare Supplement Select Plans B, C, D, M (PDF)

Medicare Supplement Plan Contract
Log in to your member account to see your plan specific contract.

To view FHCP Medicare forms & documents click here.