2022 Medicare Plan Applications
(for new enrollments)
View Optional Supplemental Dental Application
Prescription Claim Form
- Medical Claim FormOpen a PDF
- 2022 Silver&Fit Claim FormOpen a PDF - Use this form for out-of-network claims for plan year 2022
- Transplant Travel and Lodging Claim formOpen a PDF
- Dental Claim FormOpen a PDF
- International Claim Form (English)Open a PDF
- International Claim Form (Spanish)Open a PDF
Modal for Select a Dental Application for your County
Excellus BlueCross BlueShield is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_8094_C.
This page last updated 10-01-2021.