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Claim Forms

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Medicare Help Center | Forms | Claims Forms

If you paid out-of-pocket for services you think we should cover, use one of these forms to submit a claim to us.

When you go to a doctor or pharmacy outside your plan's network, you might have to pay for the visit or drug in full up front. But if you think we cover the service, you can ask us to reimburse you for what we owe. You'll just need to fill out one of these claim forms.

Choose your health plan below to find the form and instructions for sending it in.

If you have any questions, call the phone number on the back of your Blues ID card and we’ll help.

What you'll need:

  • Your Blues ID card
  • Original receipts from your doctor, pharmacy, etc.

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Page Last Updated Mon Feb 23 15:38:45 EST 2015