Medicare Forms and Documents

2020 Documents

View and download key forms and documents about your plan - including plan documents and forms for Medicare Advantage, Medicare Supplement and Prescription Drug plan members.

General Forms & Documents

Your Member Rights and More Brochure Medicare HMO (PDF)

Automatic Payment Form - Medicare Advantage

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

Protected Health Information Authorization

Appointment of Representative Form

Exceptions, Appeals & Grievances Forms

For more information on how to file a grievance, Click here.

Find forms and documents to help you manage your plan.

BlueMedicare Choice (Regional PPO)

BlueMedicare Select (PPO)

BlueMedicare Value (PPO)

BlueMedicare Classic (HMO)

BlueMedicare Saver (HMO)

BlueMedicare Classic Plus (HMO)

BlueMedicare Premier (HMO)

BlueMedicare Complete (HMO SNP)

BlueMedicare Premier Rx (PDP)

BlueMedicare Complete Rx (PDP)

Find drug and/or utilization management information, 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.

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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

2021 Documents

View and download key forms and documents about your plan - including plan documents and forms for Medicare Advantage, Medicare Supplement and Prescription Drug plan members.

Your Member Rights and More Brochure Medicare HMO (PDF)

Automatic Payment Form - Medicare Advantage (PDF)

Automatic Payment Form - Medicare Supplement (PDF)

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

Protected Health Information Authorization

Appointment of Representative Form

For more information on how to file a grievance, click here.

Find forms and documents to help you manage your plan.

BlueMedicare Classic (HMO)

BlueMedicare Premier (HMO)

BlueMedicare Complete (HMO D-SNP)

BlueMedicare Saver (HMO)