Medical claim form

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

Medicare Plus Blue PPO Member Reimbursement Form (PDF)

Mail to:

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Blue Cross Blue Shield of Michigan
Imaging and Support Services
P.O. Box 32593
Detroit, MI 48232-0593
 
 

Dental claim form

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

Dental Claim Reimbursement Form (PDF)

Mail to:

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Blue Cross Blue Shield of Michigan
P.O. Box 491
Milwaukee, WI 53201

Prescription claim form

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

Medicare Plus Blue Part D Prescription Drug Claims 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 608-741-5483