Administrative Forms
Claims
Coverage Determination Form
A beneficiary, a beneficiary's representative, or a beneficiary's prescriber may use this form to request a coverage determination (prior authorization, exception, etc.) from your Medicare Advantage plan.
Health Care Proxy Form
Complete this New York State document to legally appoint someone you trust, such as a family member or close friend, as your healthcare agent; to make healthcare decisions for you if you lose the ability to make decisions for yourself.
Medicare Advantage Request for Appeal
For use when appealing the denial of a service or claim. Appeal requests must be made within 60 calendar days of the denial notification.
Pharmacy
Medicare Part-D Prescription Drug Claims Form
Complete this Medicare Part D Prescription Drug Claim Form to request reimbursement for Medicare Part D prescription drug benefits if you did not receive coverage at a pharmacy.
Drug Mail Order Form
Use this form for Home Delivery through Express Scripts
Request for Redetermination Part D Prescription Drug Denial
If BlueCross BlueShield of Western New York denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.
Vision
Out-of-Network Vision Services Claim Form
Complete this form if you are visiting a provider that is not a participating provider in the EyeMed network. For vision reimbursement claims through 12/31/20 please submit to EyeMed.
- EyeMed Vision Services Claim Form
- Davis Vision Reimbursement Claim Form
Use this form to request reimbursement for services received from providers who do not participate in the Davis Vision network. (Available 1/1/2021)
Dental
Medicare Advantage Dental Receipt Reimbursement
Medicare Questions?
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Content Last Updated: January 8, 2021