Brochures & Forms

Claim forms and brochures for Service Benefit Plan members

Plan Brochures

2015 Blue Cross and Blue Shield Service Benefit Plan Brochure

2015 Blue Cross and Blue Shield Service Benefit Plan Brochure

Please note the following correction to the 2015 printed brochure: The first paragraph on page 49 under “Reproductive services (continued)” should read, “The services listed below are not covered as treatments for infertility or as alternatives to conventional conception.” The last word should be “conception,” not “contraception” as it is printed.

Order a Printed Brochure
2014 Blue Cross and Blue Shield Service Benefit Plan Brochure

2014 Blue Cross and Blue Shield Service Benefit Plan Brochure

2015 Standard & Basic Option Service Benefit Plan Summary

2015 Standard & Basic Option Service Benefit Plan Summary

2014 Standard & Basic Option Service Benefit Plan Summary

2014 Standard & Basic Option Service Benefit Plan Summary

2015 Standard Option Summary of Benefits and Coverage

2015 Standard Option Summary of Benefits and Coverage

2014 Standard Option Summary of Benefits and Coverage

2014 Standard Option Summary of Benefits and Coverage

2015 Basic Option Summary of Benefits and Coverage

2015 Basic Option Summary of Benefits and Coverage

2014 Basic Option Summary of Benefits and Coverage

2014 Basic Option Summary of Benefits and Coverage

2014 Straight Talk

2014 Straight Talk

The Blue Cross and Blue Shield Service Benefit Plan newsletter for a first look at what's new.

Glossary of Health Coverage and Medical Terms

Glossary of Health Coverage and Medical Terms

Download a Form

Health Benefits Claim Form

If you use a provider outside of the network, you will need to complete and file a claim form for reimbursement.

English (PDF 0.59MB)
Español (PDF 0.19MB)

Dental Benefits Claim Form

If you take advantage of Service Benefit Plan dental benefits, you will need to complete and file a claim form for reimbursement.

English (PDF 0.82MB)

Retail Prescription Drug Claim Form

Use this form to file a claim for reimbursement for retail prescriptions.

English (PDF 0.55MB)
Spanish (PDF 0.14MB)

Mail Service Prescription Drug Form (Standard Option only)

Use this form to order a mail order prescription. This is available for Standard Option members only.

English (PDF 1.12MB)
Español (PDF 1.14MB)

Overseas Medical Claim Form

Overseas members will need to complete and file this claim form for any pharmacy services received.

English (PDF 0.64MB)

Overseas Retail Pharmacy Claim Form

Overseas members will need to complete and file this claim form for any pharmacy services received.

English (PDF 0.32MB)
Español (PDF 0.14MB)

Formulary Tier Exception Member Request Form

For all formulary tier exceptions you will need to complete and file a request form. 

English (PDF 0.09MB)

Specialty Formulary Tier Exception Member Request Form

For all speciality formulary tier exceptions you will need to complete and file a request form. 

English (PDF 0.09MB)

Specialty Medication Order Form

Order form for specialty medications

English (PDF 0.50MB)

AXA Provider Nomination Form

Should you wish to request to recruit a facility or physician into the AXA network, please complete this nomination form.

English (PDF 0.15MB)

Health Benefits Election Form (SF 2809 Form)

To enroll, reenroll, or to elect not to enroll in the FEHB Program, or to change, cancel or suspend your FEHB enrollment please complete and file this form.

English (PDF 1.46MB)

Primary Breast Cancer Prevention Coverage Member Request Form

Complete the Member Request Form for Primary Breast Cancer Prevention Coverage.

English (PDF 0.10MB)

Prior Approval Retail Pharmacy Forms

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

Medical Policies

The policies contained in the FEP Medical Policy Manual are developed to assist in administering contractual benefits and do not constitute medical advice. They are not intended to replace or substitute for the independent medical judgment of a practitioner or other health care professional in the treatment of an individual member. The Blue Cross and Blue Shield Association does not intend by the FEP Medical Policy Manual, or by any particular medical policy, to recommend, advocate, encourage or discourage any particular medical technologies. Medical decisions relative to medical technologies are to be made strictly by members/patients in consultation with their health care providers. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that the Blue Cross and Blue Shield Service Benefit Plan covers (or pays for) this service or supply for a particular member.

I have read the above agreement and I agree.