Brochures & Forms

Claim forms and brochures for Service Benefit Plan members.

Plan Brochures

2020 Blue Cross and Blue Shield Service Benefit Plan Brochure - Standard and Basic Options

2020 Blue Cross and Blue Shield Service Benefit Plan Brochure - Standard and Basic Options

2020 Blue Cross and Blue Shield Service Benefit Plan Brochure - FEP Blue Focus

2020 Blue Cross and Blue Shield Service Benefit Plan Brochure - FEP Blue Focus

2020 Benefits Summary Book

2020 Benefits Summary Book

2020 Benefits at a Glance

2020 Benefits at a Glance

2020 Medicare and Blue

2020 Medicare and Blue

2020 Standard Option Summary of Benefits and Coverage

2020 Standard Option Summary of Benefits and Coverage

2020 Basic Option Summary of Benefits and Coverage

2020 Basic Option Summary of Benefits and Coverage

2020 FEP Blue Focus Summary of Benefits and Coverage

2020 FEP Blue Focus Summary of Benefits and Coverage

2019 Blue Cross and Blue Shield Service Benefit Plan Brochure - Standard and Basic Option

2019 Blue Cross and Blue Shield Service Benefit Plan Brochure - Standard and Basic Option

To order a printed brochure call 1-800-411-BLUE (2583).

2019 Blue Cross and Blue Shield Service Benefit Plan Brochure - FEP Blue Focus

2019 Blue Cross and Blue Shield Service Benefit Plan Brochure - FEP Blue Focus

To order a printed brochure call 1-800-411-BLUE (2583).

2019 FEP Blue Focus Service Benefit Plan Summary

2019 FEP Blue Focus Service Benefit Plan Summary

2019 Standard Option Summary of Benefits and Coverage

2019 Standard Option Summary of Benefits and Coverage

2019 Basic Option Summary of Benefits and Coverage

2019 Basic Option Summary of Benefits and Coverage

2019 FEP Blue Focus Summary of Benefits and Coverage

2019 FEP Blue Focus Summary of Benefits and Coverage

2019 Overseas Program

2019 Overseas Program

2019 Annual Member Notice

2019 Annual Member Notice

Glossary of Health Coverage and Medical Terms

Glossary of Health Coverage and Medical Terms

Medical and Dental

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.

Overseas members should use the Overseas Medical Claim Form.

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.

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.

Authorized Representative Designation Form

Use this form to select an individual or entity to act on your behalf during the disputed claims process. You can find detailed instructions on how to file an appeal in the Disputed Claims Process document.

Medicare Reimbursement Account (MRA) Pay Me Back Claim Form

Use this form to request reimbursement for Medicare Part B premium expenses.

Pharmacy

Retail Prescription Drug Claim Form

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

Overseas members should use the Overseas Retail Prescription Drug Claim Form.

Mail Service Prescription Drug Form

Use this form to order a mail order prescription.

Formulary Tier Exception Member Request Form

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

Specialty Formulary Tier Exception Member Request Form

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

Specialty Medication Order Form

Use this order form for specialty medications.

Primary Breast Cancer Prevention Coverage Member Request Form

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

Prior Approval Pharmacy Forms

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

Managed Formulary Exception Form

The Managed Formulary Exception (MFE) process allows Basic Option members to apply for coverage of a “Managed Not Covered” drug at a Tier 3 cost share if they have tried and failed the covered drug(s).

Standard Option Exclusion Form

The Standard Option exclusion process allows Standard Option members to apply for coverage of an excluded drug at a Tier 3 cost share if they have tried and failed the covered drug(s).

Non-Formulary Exception Form

The Non-Formulary Exception (NFE) process allows FEP Blue Focus members to request coverage of a non-formulary drug if they have tried and failed a covered option(s).

Dispense as Written (DAW) Exception Process

The Dispense as Written exception process allows for coverage of the brand drug without paying the difference in cost between brand and generic.

New to Market FDA-Approved Medication Review Exception Process

The New to Market FDA-Approved Medication Review Exception Process allows a member to apply for coverage of an excluded drug at a tier 3 cost share if the member has met the requirements outlined.

Overseas

Overseas Medical Claim Form

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

Retail Prescription Drug Overseas Claim Form

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

GMMI Overseas Provider Nomination Form

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

FEP BlueVision®

FEP BlueVision Claim Form

FEP BlueVision is neither offered nor guaranteed under contract with the FEHB Program, but is available to all enrollees and family members who become members of FEP BlueVision.

Need to Submit a Claim?

Get step by step instructions on how to download and complete the appropriate form for health benefit claims, dental claims, Medicare Reimbursement Account claims, pharmacy claims, overseas claims and FEP BlueVision direct reimbursement claims.

Learn More

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