Provider Directory

Form Library

Need a claims form? If you use a provider or hospital that participates in the Blue Cross and Blue Shield Service Benefit Plan network, you will not have to fill out any claim forms - the provider will take care of it for you. In situations where you use a provider outside of the network, receive care overseas or require prior approval for a medication, you will need to complete and file a claim form to be reimbursed by your health plan. 

To download these forms online, choose from the menu below.

Health Benefits Claim Form

English [PDF 79 KB]
En Español [PDF 194 KB]


Dental Benefits Claim Form

English [PDF 125 KB]


Retail Prescription Drug Claim Form

English [PDF 175 KB]
En Español [PDF 74 KB]


  

Mail Service Prescription Drug Form (Standard Option only)

English [PDF 1 MB]
En Español [PDF 1 MB]

  

Overseas Medical Claim Form

English [PDF 614 KB]


Overseas Retail Pharmacy Claim Form

English [PDF 176 KB]
En Español [PDF 149 KB]


Formulary Tier Exception Member Request Form 

English [PDF 96 KB]


Specialty Formulary Tier Exception Member Request Form 

English [PDF 95 KB]


2013 AXA Provider Nomination Form

English [PDF 90 KB]


Health Benefits Election Form (SF 2809 Form)

English [PDF 1.5 MB]

 

Prior Approval Retail Pharmacy Forms

For more information about Pharmacy Prior Approval and the required forms visit CVS Caremark Prior Approval page.

Page last updated: June 30, 2014

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