Instructions for Appointment of Representative

Enroll in 2010 plans.

You may appoint a relative, friend, advocate, attorney or your physician to act as your representative. A representative who is appointed by the court or who is active in accordance with State law may also file an appeal for you. To appoint a representative you must complete an Appointment of Representative form (PDF 67K).

For incapacitated or legally incompetent enrollees where there are appropriate legal papers or other legal authority, such supporting documentation may be submitted as evidence of representation.

How to Complete This Form

Please print or type. At the top, show your full name and Medicare Number. If you appoint more than one person, you may want to complete a form for each of them.

Section I: Appointment of Representative

Give the name and address of the person(s) you are appointing. You may appoint an attorney or any other qualified person to represent you. You may appoint one or more persons in a firm, corporation, or other organization as your representative(s), but you may not appoint a law firm, legal aid group, corporation, or organization itself. In addition, you must date and sign this section as the beneficiary, and provide your address, and phone number.

Section II: Acceptance of Appointment

Each person you appoint (named in Section I) completes this section. If the individual is not an attorney, he or she must provide his or her name, state that he or she accepts the appointment, and sign the appointment.

Section III: Waiver of Fee for Representation

Your representative may complete and sign this section if he or she will not charge any fee for the representation provided.

A new form must be submitted with each grievance and appeal you submit.

Download the form needed to appoint a representative:

Appointment of Representative form (67K PDF)

Return to Grievances, Coverage Determinations and Appeals page

Medicare Plus Blue PPO^SM and Medicare Plus Blue PFFS^SM are health plans with Medicare contracts. Prescription Blue PDP^SM is a stand-alone prescription drug plan with a Medicare contract.

Important information about these plans

Medicare Plus Blue PPO^SM is available in these counties: Alcona, Alger, Allegan, Alpena, Arenac, Baraga, Barry, Bay, Berrien, Branch, Calhoun, Cass, Chippewa, Clare, Clinton, Crawford, Delta, Dickinson, Eaton, Genesee, Gladwin, Gogebic, Gratiot, Hillsdale, Houghton, Huron, Ingham, Ionia, Iosco, Iron, Isabella, Jackson, Kalamazoo, Kent, Keweenaw, Lake, Lapeer, Lenawee, Livingston, Luce, Mackinac, Macomb, Manistee, Marquette, Mason, Mecosta, Menominee, Midland, Missaukee, Monroe, Montcalm, Montmorency, Muskegon, Newaygo, Oakland, Oceana, Ogemaw, Ontonagon, Osceola, Oscoda, Otsego, Ottawa, Presque Isle, Roscommon, Saginaw, Sanilac, Schoolcraft, Shiawassee, St. Clair, St. Joseph, Tuscola, Van Buren, Washtenaw, Wayne, Wexford.

With the exception of emergency or urgent care, it will cost more to get care from non-plan or non-preferred providers. Your responsibility will be greater out-of-network when the out-of-network coinsurance is based on the Medicare allowed amount and the contracted amount is lower. You may receive services from any provider who accepts your Medicare Plus Blue PPO^SM ID card. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit bcbsm.com/medicare/search.shtml.

Medicare Plus Blue PPO^SM provides reimbursement for all covered benefits regardless of whether they are received in-network, as long as they are medically necessary.

Medicare Plus Blue PFFS^SM
Medicare Plus Blue PFFS^SM is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and enrolled in Part B.

A Medicare Advantage private fee-for-service plan works differently than a Medicare supplement plan. Your doctor or hospital can continue to treat you if it agrees to accept our terms and conditions of payment, and thus may choose not to treat you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may choose not to provide health care services to you, except in emergencies. Providers can find the plan's terms and conditions on our Web site at bcbsm.com/ma. You can also read more about how private fee-for-service plans work for you in our downloadable flyer (PDF 160K).

Prescription Blue PDP^SM
Prescription Blue PDP^SM is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and/or enrolled in Part B.

Medicare beneficiaries enrolled in a Medicare Advantage PFFS plan that includes Medicare prescription drugs or any Medicare Advantage coordinated care (HMO or PPO) plan will be automatically disenrolled from the HMO, PPO or Medicare Advantage PFFS plan if they enroll in a prescription drug plan; and Medicare beneficiaries enrolled in a private fee-for-service plan (PFFS) that does not include Medicare prescription drug coverage, a Medicare Advantage Medicare Savings Account (MSA) plan or an 1876 Cost plan may enroll in a prescription drug plan and will not be automatically disenrolled from the PFFS, MSA or 1876 Cost plan.

Medicare Plus Blue PPO^SM, Medicare Plus Blue PFFS^SM and Prescription Blue PDP^SM
Premiums vary by county. You must continue to pay your Medicare Part B premium.

In Michigan, 86 percent of pharmacies are network pharmacies; nationwide, more than 80 percent of pharmacies are in the network, including the majority of chain pharmacies, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies (Source: 2010 Pharmacy Directory). In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Cross Blue Shield of Michigan. For additional information on network pharmacies, please call Customer Service at 1-877-469-2583, 8 a.m. to 8 p.m., seven days a week. TTY users should call 1-800-481-8704. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X435, Detroit, MI 48226.

If you decide to have your plan premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.

The benefit information provided herein is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement; for more information contact the plan Benefits, formulary, pharmacy, network, premium and/or coinsurance may change on Jan. 1, 2011. Please contact Blue Cross Blue Shield of Michigan for details.

In addition to enrolling through this Web site, Medicare beneficiaries may enroll in Medicare Plus Blue PPO^SM, Medicare Plus Blue PFFS^SM or Prescription Blue PDP^SM through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at medicare.gov. For more information, please contact Blue Cross Blue Shield of Michigan at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. You may only enroll in Medicare Plus Blue PPO^SM, Medicare Plus Blue PFFS^SM or Prescription Blue PDP^SM during specific times of the year. To learn more about enrollment periods, please contact Customer Service.

This document is available in alternate formats or languages. For more information, call 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704.

Medicare Plus Blue PPO^SM, Medicare Plus Blue PFFS^SM and Prescription Blue PDP^SM are issued by Blue Cross Blue Shield of Michigan, which contracts with the federal government. Medicare Plus Blue PPO^SM, Medicare Plus Blue PFFS^SM and Prescription Blue PDP's^SM contracts with CMS are renewed annually and the availability of coverage beyond the end of the contract year is not guaranteed.

Medicare Plus Blue PPO^SM
Medicare Plus Blue PPO^SM is available to all Medicare beneficiaries who are Michigan residents who reside within the plan's 75-county service area and are entitled to receive services under Medicare Part A and enrolled in Part B.
Medicare Plus Blue PPO^SM is available in these counties: Alcona, Alger, Allegan, Alpena, Arenac, Baraga, Barry, Bay, Berrien, Branch, Calhoun, Cass, Chippewa, Clare, Clinton, Crawford, Delta, Dickinson, Eaton, Genesee, Gladwin, Gogebic, Gratiot, Hillsdale, Houghton, Huron, Ingham, Ionia, Iosco, Iron, Isabella, Jackson, Kalamazoo, Kent, Keweenaw, Lake, Lapeer, Lenawee, Livingston, Luce, Mackinac, Macomb, Manistee, Marquette, Mason, Mecosta, Menominee, Midland, Missaukee, Monroe, Montcalm, Montmorency, Muskegon, Newaygo, Oakland, Oceana, Ogemaw, Ontonagon, Osceola, Oscoda, Otsego, Ottawa, Presque Isle, Roscommon, Saginaw, Sanilac, Schoolcraft, Shiawassee, St. Clair, St. Joseph, Tuscola, Van Buren, Washtenaw, Wayne, Wexford.
With the exception of emergency or urgent care, it will cost more to get care from non-plan or non-preferred providers. Your responsibility will be greater out-of-network when the out-of-network coinsurance is based on the Medicare allowed amount and the contracted amount is lower. You may receive services from any provider who accepts your Medicare Plus Blue PPO^SM ID card. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit bcbsm.com/medicare/search.shtml.
Medicare Plus Blue PPO^SM provides reimbursement for all covered benefits regardless of whether they are received in-network, as long as they are medically necessary.
Medicare Plus Blue PFFS^SM
Medicare Plus Blue PFFS^SM is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and enrolled in Part B.
A Medicare Advantage private fee-for-service plan works differently than a Medicare supplement plan. Your doctor or hospital can continue to treat you if it agrees to accept our terms and conditions of payment, and thus may choose not to treat you, with the exception of emergencies. If your doctor or hospital does not agree to accept our payment terms and conditions, they may choose not to provide health care services to you, except in emergencies. Providers can find the plan's terms and conditions on our Web site at bcbsm.com/ma. You can also read more about how private fee-for-service plans work for you in our downloadable flyer (PDF 160K).
Prescription Blue PDP^SM
Prescription Blue PDP^SM is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and/or enrolled in Part B.
Medicare beneficiaries enrolled in a Medicare Advantage PFFS plan that includes Medicare prescription drugs or any Medicare Advantage coordinated care (HMO or PPO) plan will be automatically disenrolled from the HMO, PPO or Medicare Advantage PFFS plan if they enroll in a prescription drug plan; and Medicare beneficiaries enrolled in a private fee-for-service plan (PFFS) that does not include Medicare prescription drug coverage, a Medicare Advantage Medicare Savings Account (MSA) plan or an 1876 Cost plan may enroll in a prescription drug plan and will not be automatically disenrolled from the PFFS, MSA or 1876 Cost plan.
Medicare Plus Blue PPO^SM, Medicare Plus Blue PFFS^SM and Prescription Blue PDP^SM
Premiums vary by county. You must continue to pay your Medicare Part B premium.
In Michigan, 86 percent of pharmacies are network pharmacies; nationwide, more than 80 percent of pharmacies are in the network, including the majority of chain pharmacies, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies (Source: 2010 Pharmacy Directory). In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Cross Blue Shield of Michigan. For additional information on network pharmacies, please call Customer Service at 1-877-469-2583, 8 a.m. to 8 p.m., seven days a week. TTY users should call 1-800-481-8704. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X435, Detroit, MI 48226.
If you decide to have your plan premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.
The benefit information provided herein is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement; for more information contact the plan Benefits, formulary, pharmacy, network, premium and/or coinsurance may change on Jan. 1, 2011. Please contact Blue Cross Blue Shield of Michigan for details.
In addition to enrolling through this Web site, Medicare beneficiaries may enroll in Medicare Plus Blue PPO^SM, Medicare Plus Blue PFFS^SM or Prescription Blue PDP^SM through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at medicare.gov. For more information, please contact Blue Cross Blue Shield of Michigan at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. You may only enroll in Medicare Plus Blue PPO^SM, Medicare Plus Blue PFFS^SM or Prescription Blue PDP^SM during specific times of the year. To learn more about enrollment periods, please contact Customer Service.
This document is available in alternate formats or languages. For more information, call 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704.
Medicare Plus Blue PPO^SM, Medicare Plus Blue PFFS^SM and Prescription Blue PDP^SM are issued by Blue Cross Blue Shield of Michigan, which contracts with the federal government. Medicare Plus Blue PPO^SM, Medicare Plus Blue PFFS^SM and Prescription Blue PDP's^SM contracts with CMS are renewed annually and the availability of coverage beyond the end of the contract year is not guaranteed.

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call:

1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day, seven days a week;
The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778; or
Your State Medicaid Office.

H9572 H2319 S5584 Web17rev [CMS approval xx\xx] Pending CMS approval