Member Forms

2024 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 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

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

Prescription Drug Claim FormOpen a PDF

Claim Forms

D-SNP OTC & Healthy Food Claim FormOpen a PDF
Medicare Advantage Flex Card Claim FormOpen a PDF
Medical Claim FormOpen a PDF
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

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_9775_C.

This page last updated 10-01-2023.