Medicare Member Forms

Whether you're looking to file a claim or pay your bill, find the right form to manage your Blue Cross Blue Shield of Michigan Medicare coverage here.

Log in to your online member account for a personalized experience.

Submit your request by logging in to your online account

The fastest and easiest way to get reimbursed is by logging in to your online account.

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Medicare Plus Blue PPO Member Reimbursement Form

If you have a Medicare Advantage PPO plan with us and want reimbursement for a covered medical service, fill out and send this form.

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BCN Advantage HMO and HMO-POS Member Reimbursement Form

If you have a Medicare Advantage HMO or HMO-POS plan with us and want reimbursement for a covered medical service, fill out and send this form.

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Prescription Drug Claim Reimbursement Form

If you have a Medicare Advantage or Part D plan with us and want reimbursement for a covered drug, download and send this form.

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Member Flu and Pneumonia Shots Reimbursement Form

If you got a flu or pneumonia shot and had to pay for it, fill out and send this form for reimbursement.

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Dental Claim Reimbursement Form

If you have dental coverage with us through your Medicare Advantage plan and want reimbursement for a covered dental service, download and send this form.

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Medicare Supplement Plans Authorization Agreement for Automatic Payments

Pay your Blue Cross Medicare Supplement plan automatically when you fill out and send this form.

How to Pay Your Medicare Advantage or Part D Plan Bill

If you have a Medicare Advantage or Part D plan, we don't offer a form for paying your bill. Learn how you can pay your bill with this help document.

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Optum Home Delivery Mail Order Form

Use this form if you'd like to get prescriptions by mail through Optum Home Delivery. Keep in mind, it takes about five days for us to fill your order and get it to you.

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Walgreens Mail Service Order Form

You can also get prescriptions by mail through Walgreens Mail Service. Keep in mind it takes about five days for us to fill your order and get it to you.

ONLINE FORM

Prescription Drug Coverage Determination Online Form

If you want Blue Cross to make an exception for a drug, you can ask us for a coverage determination. You'll need information about the drug you want covered and the name and contact information of the doctor who prescribed the drug.

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Prescription Drug Coverage Determination Paper Form

You can also fill out and mail this form to ask for an exception for a prescription drug.

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Medicare Plus Blue PPO and Prescription Blue PDP Request for Redetermination Form

If you have a Medicare Plus Blue PPO or Prescription Blue PDP plan and want to appeal a decision we've already made about a prescription drug, you can ask us to review it with this form. If possible, include the letter you received from us that you'd like to appeal.

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BCN Advantage HMO and HMO-POS Request for Redetermination Form

If you have a BCN Advantage HMO or HMO-POS plan and want to appeal a decision we've already made about a prescription drug, you can ask us to review it with this form. If possible, include the letter you received from us that you'd like to appeal.

ONLINE FORM

Consent for Release of PHI for Medicare Plus Blue PPO and Prescription Blue PDP Members

If you have one of our Medicare Plus Blue PPO or Prescription Blue PDP plans and want to access your own PHI or share it with someone you designate, you can fill out this digital form.

ONLINE FORM

Consent for Release of PHI for BCN Advantage HMO and HMO-POS Members

If you have one of our BCN Advantage HMO or HMO-POS plans and want to access your own PHI or share it with someone you designate, you can fill out this digital form.

ONLINE FORM

Consent for Release of PHI for Blue Cross Medicare Supplement Members

If you have one of our Medicare supplement plans and want to access your own PHI or share it with someone you designate, you can fill out this digital form.

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Consent for Release of PHI for Medicare Members

You can also fill out and send us this printable form if you want to access your PHI.

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Appointment of Representative Form

This form lets you pick a person like a spouse, friend, family member, lawyer or caregiver to act on your behalf regarding Medicare coverage decisions, appeals and grievances. Note: You can't pick a law firm or group to help you.

Medicare plan enrollment forms

You can enroll in one of our Medicare plans by mail with these forms.

Looking for Medicare plan documents?

Learn about your benefits, covered drugs and more with plan documents like your Summary of Benefits.

2027 plan documents

2026 plan documents

Important information about Medicare supplement plans

This is a solicitation of insurance. We may contact you about buying insurance. Blue Cross Medicare SupplementSM plans aren't connected with or endorsed by the U.S. government or the federal Medicare program.

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