Forms and Documents

Forms and Documents

Log in to Blue Access for Members℠  to view your plan documents. This secure, online account and mobile app provides easy access to your health benefit information anytime, anywhere.

To download the app, text BCBSMTAPP to 33633, or search for BCBSMT in the Apple App Store or in Google Play . (Message and data rates may apply.)

If you have questions about your plan documents, call the number listed on your Blue Cross and Blue Shield of Montana member ID card.

General Plan Information

• Automated Premium Payment (ACH) Form (MAPD)
  
• CMS Appointment of Representative Form (MAPD)

Prescription Drug Information

• Mail-Order Physician New Prescription Fax Form
• Medicare Part B vs. Part D Form
• Medicare Prescription Payment Plan Enrollment Form (MAPD)
• Online Coverage Determination Request Form
• Online Coverage Redetermination Request Form
• Personal Medication List 
• Pharmacy Mail-Order Form  
• Prescription Drug Claim Form
• Prescription Drug Coverage Determination Request Form (MAPD)
• Prescription Drug Coverage Redetermination Request Form (MAPD)
• Prescription Drug Formulary Exception Physician Form
• Prescription Drug Tier Exception Physician Form

Other

• Access Additional Privacy Forms 
• Authorization to Disclose Protected Health Information (PHI) Form 
• Late Enrollment Penalty (LEP) Appeals
• Notice of Privacy Practices

If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form or contact the Office of the Medicare Ombudsman