Medical claim form

If you're asking for reimbursement for a medical service that's covered by your BCN Advantage plan, download and fill out this form:

BCN Advantage Member Reimbursement Form (PDF)

Mail or fax to:

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Blue Care Network
Member Reimbursements – G804
P.O. Box 68753
Grand Rapids, MI 49516-8753
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Fax to 866-637-4972

Prescription claim form

If you're asking for reimbursement for a prescription drug that's covered by your BCN Advantage plan, download and fill out this form:

Coordination of Benefits/Direct Claim Form (PDF)

Mail or fax to:

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Express Scripts
ATTN: Medicare Part D
P.O. Box 14718 
Lexington, KY 40512
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Fax to 800-459-8027