Member Forms

2023 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 - Jefferson - Lewis - Madison - Oneida - Onondaga - Oswego - St. Lawrence - Schuyler - Steuben - Tioga - Tompkins
Medicare Bassett HMO-POS,
Medicare BlueActive PPO,
Medicare BlueClassic PPO,
Medicare BlueEnhanced PPO,
Medicare BlueEssential PPO,
Medicare BlueFlex PPO,
Medicare BlueSalute PPO 		CNY Herkimer
Medicare BluePlus PPO,
Medicare BlueSalute PPO 		East Clinton - Delaware - Essex - Franklin - Fulton - Hamilton - Montgomery - Otsego
Medicare Bassett HMO-POS,
Medicare BluePlus PPO,
Medicare BlueSalute PPO		 East Delaware - Otsego
Medicare Blue Choice Access PPO,
Medicare Blue Choice Advanced HMO-POS,
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

General Forms

Other Forms

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.

 

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