Claim Forms

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.

BCBS FEP Dental 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.

Medicare Reimbursement Account (MRA) Pay Me Back Claim Form

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

Pregnancy Blood Pressure Monitor Request Form

Pregnant members can use this form to request a blood pressure monitor at no cost.

Disputed Claims Process Document

You can find detailed instructions on how to file an appeal in this document.

Family Planning Exception Member Request Form

Use this form to request an exception for a surgical procedure that can be performed as contraceptive therapy that isn't listed in your plan brochure.

Retail Prescription Drug Claim Form

Complete this claim form for any traditional pharmacy services received.

Mail Service Prescription Drug Form

Use this form to order a mail order prescription.

Specialty Medication Order Form

Use this order form for specialty medications.

Prior Approval Pharmacy Forms

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

Formulary Exception Form

The Formulary Exception process allows members to apply for coverage of a non-covered drug if they have tried and failed the covered drug(s). Select the list of exceptions for your plan.

Tier Exception Member Request Form

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

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.

ACA Breast Cancer Prevention Coverage Member Request Form

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

Contraceptive Exception Form

The Contraceptive Exception Form allows members to apply for coverage, or formulary tier, exception for a contraceptive drug/product.

ACA Bowel Prep Prevention Coverage Member Request Form

Complete the Member Request Form for ACA Bowel Prep Prevention Coverage.

ACA HIV Prevention Coverage Member Request Form

Complete the Member Request Form for ACA HIV Prevention Coverage.

MPDP Claim Form

Use this form to submit your MPDP prescription claims via mail. Mail the completed form with receipts to CVS Caremark Medicare Part D Processing, P.O. Box 52066, Phoenix, AZ 85072-2066.

Overseas Medical Claim Form

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

Retail Prescription Drug Claim Form

Overseas members will need to complete and file this claim form for any pharmacy services received. Members enrolled in MPDP need to complete and submit the MPDP claim form available above.

GeoBlue Overseas Provider Nomination Form

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