Member Services

Forms

This Forms and Brochures section provides you with easy access to the materials you will need to complete various tasks related to your coverage, such as ordering a member ID card, requesting a pharmacy directory, appealing a provision of your plan, or filling prescriptions in a retail pharmacy or by mail order. Please see below for a complete list of forms/options.

MedicareBlue PPO (Regional PPO)

Iowa Reimbursement Medical Claim Form (PDF)
Minnesota Reimbursement Medical Claim Form (PDF)
Montana Reimbursement Medical Claim Form (PDF)
North Dakota Reimbursement Medical Claim Form (PDF)
Nebraska Reimbursement Medical Claim Form (PDF)
South Dakota Reimbursement Medical Claim Form (PDF)
Wyoming Reimbursement Medical Claim Form (PDF)

Vaccine Claims Submission Instructions (PDF)

MedicareBlue Rx (PDP)

Provider Forms

September 06, 2010

Important Information

This page last updated and accepted by CMS July, 2010.

MedicareBlue Rx (PDP) is a Medicare-approved Part D sponsor. MedicareBlue PPO (Regional PPO) is a Medicare-approved regional PPO plan.

Coverage is available to residents of the service area or members of an employer or union group and separately issued by one of the following plans: Wellmark Blue Cross and Blue Shield of Iowa,* Blue Cross and Blue Shield of Minnesota,* Blue Cross and Blue Shield of Montana,* Blue Cross and Blue Shield of Nebraska,* Blue Cross Blue Shield of North Dakota,* Wellmark Blue Cross and Blue Shield of South Dakota,* and Blue Cross Blue Shield of Wyoming.*

*Independent licensees of the Blue Cross and Blue Shield Association.