Medicare Forms

Late Enrollment Penalty (LEP) Appeals

Medicare beneficiaries may incur a late enrollment penalty (LEP) if there is a continuous period of 63 days or more at any time after the end of the individual's Part D initial enrollment period during which the individual was eligible to enroll but was not enrolled in a Medicare Part D plan and was not covered under any creditable prescription drug coverage.

Information about LEP

Information about LEP appeals

LEP Appeal Form

Medicare Advantage (Part C): Appeals & Grievances

You have the right to file a grievance or submit an appeal and ask us to review your coverage determination.

How to file an Appeal or Grievance

Appeals & Grievances Form

Rights and Responsibilities upon Disenrollment: You have the right to ask us to reconsider this decision. You can ask us to reconsider by filing a grievance with us. You can look in your “Evidence of Coverage” for information about how to file a grievance, contact us at 1-800-926-6565 (TTY users: 1-800-955-8770) or click here for more information. Upon request, Medicare Advantage plans are required to disclose grievance and appeals data to Medicare Advantage enrollees in accordance with the regulatory requirements. You can contact us at 1-800-926-6565 (TTY users: 1-800-955-8770) to request this information.

Prescription Drug (Part D): Appeals & Grievances

You have the right to file a grievance or submit an appeal and ask us to review your coverage determination.

How to file an Appeal or Grievance

Coverage Determination Form

Coverage Redetermination Form

Rights and Responsibilities upon Disenrollment: You have the right to ask us to reconsider this decision. You can ask us to reconsider by filing a grievance with us. You can look in your “Evidence of Coverage” for information about how to file a grievance, contact us at 1-800-926-6565 (TTY users: 1-800-955-8770) or click here for more information. Upon request, Prescription Drug plans are required to disclose grievance and appeals data to Prescription Drug enrollees in accordance with the regulatory requirements. You can contact us at 1-800-926-6565 (TTY users: 1-800-955-8770) to request this information.

Appoint a Representative

You can appoint someone to act on your behalf. Go to Medicare.gov to download a form to Appointment of Representative.

Go to Medicare.gov

Send a complaint to Medicare

You can file a complaint about your Medicare health or drug plan. Go to Medicare.gov to file a Medicare Complaint Form.

Go to Medicare.gov

Your Member Rights

Your Member Rights and More (Part C HMO plans)

Prior Authorization Request

Prior Authorization Request for Medicare Coverage of Service

Automatic Payment Option (APO)

Automatic Payment Option (APO) Form - Medicare Advantage

Claims

Pharmacy Claim Form

Medical Claim Form (for medical services in the U.S., including cruise ships departing the U.S.)

Medical Claims Form BCBS Global Core

Medication Therapy Management Program (MTM)

Visit the MTM Program page for Florida Blue members enrolled in Medicare Advantage HMO, LPPO and RPPO (Part C) plans. 

Medicare Part B Step Therapy

Medicare Part B - Prior Authorization Request Form

Prime Therapeutics

Visit MyPrime.com to find prescription drug forms and information, such as claim forms and formularies. You will be asked a few questions so the site can determine which set of forms to show you.

2023 Medicare Part D - Prior Authorization Criteria

2023 Medicare Part D - Step Therapy

Prime Therapeutics

Visit MyPrime.com to find prescription drug forms and information, such as claim forms and formularies. You will be asked a few questions so the site can determine which set of forms to show you.

2023 Medicare Part D - Prior Authorization Criteria

2023 Medicare Part D - Step Therapy

Automatic Payment

Automatic Payment Form - Prescription Drug Plans

Claims

Pharmacy Claim Form

Medication Therapy Management Program (MTM)

Visit the MTM Program page for Florida Blue members enrolled in stand-alone Medicare Prescription Drug (Part D) plans. 

If your prescription drug coverage is not from Florida Blue Medicare (through our pharmacy benefits manager, Prime Therapeutics), please contact your pharmacy benefits administrator for the forms you need.