Member Forms

2022 Medicare Plan Applications

(for new enrollments)

View Optional Supplemental Dental Application

Medicare Advantage Plan Application for Region in these Counties
Medicare BlueActive PPO, Medicare BlueBasic PPO, Medicare BlueClassic PPO, Medicare BlueSecure PPO, Medicare BlueEnhanced PPO, Medicare BlueEssential PPO CNY Broome - Cayuga - Chemung - Chenango - Cortland - Jefferson - Lewis - Madison - Oneida - Onondaga - Oswego - St. Lawrence - Schuyler - Steuben - Tioga - Tompkins
Medicare BlueActive PPO, Medicare BlueBasic PPO, Medicare BlueClassic PPO, Medicare BlueSecure PPO, Medicare BlueEnhanced PPO, Medicare BlueEssential PPO, Medicare Bassett HMO-POS CNY Herkimer
Medicare BlueBasic PPO, Medicare BluePlus PPO East Clinton - Delaware - Essex - Franklin - Fulton - Hamilton - Montgomery - Otsego
Medicare Bassett HMO-POS East Delaware - Otsego
Medicare Blue Choice Value HMO, Medicare Blue Choice Value Plus HMO-POS, Medicare Blue Choice Advanced HMO-POS, Medicare Blue Choice Optimum HMO-POS, Medicare Blue Choice Platinum HMO-POS, Medicare Blue Choice Select HMO Rochester Livingston - Monroe - Ontario - Seneca - Wayne - Yates

Prescription Claim Form

Claim Forms

General Forms

Other Forms

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.

IE Browser Modal