Member Forms
2025 Medicare Plan Applications
(for new enrollments)
| Medicare Advantage Plan Application for | Region | in these Counties |
|---|---|---|
| Medicare BlueActive PPO, Medicare BlueClassic PPO, Medicare BlueEnhanced PPO, Medicare BlueEssential PPO, Medicare BlueFlex PPO, Medicare BlueSalute PPO |
CNY | Broome - Cayuga - Chemung - Chenango - Cortland - Herkimer - Jefferson - Lewis - Madison - Oneida - Onondaga - Oswego - St. Lawrence - Schuyler - Steuben - Tioga - Tompkins |
| Medicare BluePlus PPO, Medicare BlueSalute PPO |
East | Clinton - Delaware - Essex - Franklin - Fulton - Hamilton - Montgomery - Otsego |
| Medicare Blue Choice Advanced HMO-POS, Medicare Blue Choice Discovery PPO, Medicare Blue Choice Extra HMO, Medicare Blue Choice Freedom HMO-POS, Medicare Blue Choice Optimum HMO-POS, Medicare Blue Choice Select HMO, Medicare Blue Choice Value Plus HMO-POS |
Rochester | Livingston - Monroe - Ontario - Seneca - Wayne - Yates |
Prescription Claim Form
Claim Forms
- D-SNP OTC & Healthy Food Claim FormOpen a PDF
- Medicare Advantage Flex Card Claim FormOpen a PDF
- Medical Claim FormOpen a PDF
- 2024 Silver&Fit Claim Form - Use this form for out-of-network claims for plan year 2024
- Medicare Advantage Transplant Travel and Lodging Claim formOpen a PDF
- D-SNP 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
General Forms
- Manage Your Privacy
- New York Health Care Proxy form (PDF)Open a PDF
- New York Health Care Proxy form - Spanish (PDF)Open a PDF
Other Forms
Excellus BlueCross BlueShield is an HMO/PPO/HMO D-SNP plan with a Medicare contract and a contract with the New York State Medicaid program. 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_10519_C.
This page last updated 10-01-2024.
