2023 Medicare Plan Applications
(for new enrollments)
Prescription Claim Form
- Medicare Advantage Flex Card Claim FormOpen a PDF
- Medical Claim FormOpen a PDF
- 2022 Silver&Fit Claim FormOpen a PDF - Use this form for out-of-network claims for plan year 2022
- 2023 Silver&Fit Claim Form - Use this form for out-of-network claims for plan year 2023
- 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
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_8830_C.
This page last updated 10-01-2022.