Medicare Forms and Documents

Your Member Rights and More Brochure Medicare HMO (PDF)

Automatic Payment Form - Medicare Advantage

Medical Claim Form (for medical services in the U.S., including cruise ships departing the U.S.) (PDF)

BlueCard Worldwide International Claim Form (PDF)

Protected Health Information Authorization

Appointment of Representative Form

Find forms and documents to help you manage your plan.

BlueMedicare Choice (Regional PPO)

BlueMedicare Select (PPO)

BlueMedicare Value (PPO)

BlueMedicare Classic (HMO)

BlueMedicare Classic Plus (HMO)

BlueMedicare Premier (HMO)

BlueMedicare Complete (HMO SNP)

BlueMedicare Premier Rx (PDP)

BlueMedicare Complete Rx (PDP)

Find prescription drug forms and information, such as claim forms and formularies, on MyPrime.com. You will be asked a few questions so the site can determine which set of forms to show you.

Step Therapy (PDF)

Prior Authorization Criteria (PDF)

Important: If your prescription drug coverage is not from Florida Blue Medicare (through our pharmacy benefits manager, Prime Therapeutics), please contact your pharmacy benefits administrator for the forms you need.

Find forms and documents to help you manage your plan.

Automatic Payment Form - Medicare Supplement

Outline of Coverage Florida Blue Medicare Supplement Plans A, B, C, D, E, F, G, K, L, M, N

Outline of Coverage Florida Blue Medicare Supplement Select Plans B, C, D, M; Medicare Supplement Plans A, C, F

Medicare Supplement Plan Contract
Log in to your member account to see your plan specific contract.

To view FHCP Medicare forms & documents click here

HIPPA Notice of Privacy Practice

Your Member Rights and More (PDF)

Medical Claim Form (for medical services in the U.S., including cruise ships departing the U.S.) (PDF)

BlueCard Worldwide International Claim Form (PDF)

Find forms and documents to help you manage your plan.

Automatic Payment Form - Medicare Advantage (PDF)

BlueMedicare Classic (HMO)

BlueMedicare Premier (HMO)

BlueMedicare Complete (HMO D-SNP)

BlueMedicare Saver (HMO)

BlueMedicare Choice (Regional PPO)

BlueMedicare Select (PPO)

BlueMedicare Value (PPO)

BlueMedicare Patriot (PPO)

Find forms and documents to help you manage your plan.

Automatic Payment Form - Prescription Drug Plans (PDF)

BlueMedicare Premier Rx (PDP)

BlueMedicare Complete Rx (PDP)

Find prescription drug forms and information, such as claim forms and formularies, on MyPrime.com. You will be asked a few questions so the site can determine which set of forms to show you.

Step Therapy

Prior Authorization Criteria

Important: If your prescription drug coverage is not from Florida Blue Medicare (through our pharmacy benefits manager, Prime Therapeutics), please contact your pharmacy benefits administrator for the forms you need.

Find forms and documents to help you manage your plan.

Automated Payment Form - Medicare Supplement (PDF)
Take advantage of convenience security and savings with our Automatic Payment Option.

Outline of Coverage Florida Blue Medicare Supplement Plans A, B, C, D, E, F, G, K, L, M, N (PDF)

Outline of Coverage Florida Blue Medicare Supplement Select Plans B, C, D, M; Medicare Supplement Plans A, C, F (PDF)

Medicare Supplement Plan Contract
Log in to your member account to see your plan specific contract.

To view FHCP Medicare forms & documents click here