Medicare Member Forms

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

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

Prior Authorization Request
Prior Authorization Request for Medicare Coverage of Service

Automatic Payment Option (APO)
Take advantage of convenience, security, and savings with our Automatic Payment Option (APO)/ Electronic Fund Transfer (EFT). Have your premium automatically withdrawn from your checking or savings account monthly.
Automatic Payment Option (APO) Form - Medicare Advantage

Claims
Claims Form - Pharmacy
Claims Form - Dental
Claims Form - Vision
Claims Form - Medical (for medical services in the U.S., including cruise ships departing the U.S.)
Claims Form - Medical BCBS Global Core

Prescription Payment Plan
Starting in 2025, you can set up a payment plan for your prescription drugs. Learn more

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

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. 

Medicare Part B Step Therapy
For a list of Part B Drugs that may require Step Therapy: 
Step Therapy Requirements for Medicare Outpatient (Part B) Medications 
The following form must be completed by your doctor:
Medicare Part B - Prior Authorization Request Form

Prescription Payment Plan
Starting in 2025, you can set up a payment plan for your prescription drugs. Learn more

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

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. 

Automatic Payment Option (APO)
Take advantage of convenience, security, and savings with our Automatic Payment Option (APO)/ Electronic Fund Transfer (EFT). Have your premium automatically withdrawn from your checking or savings account monthly.
Automatic Payment Option (APO) Form - Prescription Drug

Claims
Claims Form - Pharmacy