Forms and Policies
Plans
- 2025 Enrollment Form
- 2024 Enrollment Form
- Low-Income Subsidy Information
- Dental Reimbursement Form
- Out of Network and Emergency Care Policy
- Medical Claim Reimbursement Form
- Disenrollment Form
- Medical Prior Authorization Request Form
- International Claims Reimbursement Form
- Medicare Advantage Procedures
Prescription Drug
- Medication Therapy Management Program
- Part D Prior Authorization
- Part D Step Therapy
- Part D Coverage Determination and Redetermination
- 2025 Transition Period Drug Benefits
- 2024 Transition Period Drug Benefits
- Medicare Part B Diabetic Testing Supplies Prescriber Fax Form
- Medicare Drug Claim Form
- Part B Drugs Requiring Prior Authorization, updated 10/30/2023
- Information on Safe Disposal of Drugs
Payments and Assistance
- Automatic Payment Withdrawal Form
- Social Security Deduction Application
- CMS Best Available Evidence Policy
- Medicare Prescription Payment Plan
Confidential and Representative
- Notice of Privacy Practices
- Appointing a Representative
You may choose someone to act on your behalf in filing a grievance, in requesting a coverage determination, and in requesting a redetermination. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.
- Release of Protected Health Information (PHI)
You may choose someone such as a family member of friend to share your Protected Health Information(PHI) with.
- Filing a Grievance or Complaint
- Rights and Responsibilities When You End Your Plan
- Non-discrimination notice and translation services
Have Questions?
Request your Medicare Options Guide
Understanding all the coverage options available may feel confusing. Get important details from Blue Cross and Blue Shield of Nebraska about Medicare options and important dates to remember.