Administrative Forms

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.

• Submit request online
• Download paper form

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.

• View health care proxy information
• Download form 

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.

• View request for appeal

Subscriber Claim Form

Medical benefits subscriber claim form

• View the subscriber claim form

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.

• View drug claim form

Drug Mail Order Form

Use this form for Home Delivery through Express Scripts

• View drug mail order form

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.

• Submit request online
• Download paper form

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
  


Use this form to request reimbursement for services received from providers who do not participate in the Davis Vision network. (Available 1/1/2021)

• Davis Vision Reimbursement Claim Form

Medicare Advantage Dental Receipt Reimbursement

• Dental Reimbursement Form