Forms and Documents List

Claims

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BCBSM Member Reimbursement Form

Usually, we pay your health care providers for you without you having to do anything. But, sometimes you have to pay the doctor or hospital yourself. This form is how you ask us to reimburse you.

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Dental Member Application for Payment Consideration

You can use the Member Application for Payment Consideration form to ask us for reimbursement for dental claims you have paid for yourself.

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Accidental Dental Member Application for Payment Consideration

You can use the Accidental Dental Member Application for Payment Consideration form to ask us for reimbursement for accidental dental claims you have paid for yourself. Accidental dental injury is defined as an external force to the lower half of the face or jaw that damages or breaks the teeth, periodontal structures or bone. Damage to the mouth by self-inflicted external force or chewing isn’t covered.

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Member Application for Payment Consideration for Metabolic Diseases and Foods

Use this form to ask for reimbursement for medical expenses related to metabolic diseases and foods.

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Blue Cross Blue Shield of Michigan Member Appeal Form

If you have a problem with your Blue Cross Blue Shield of Michigan service, you can use this form to file an appeal with us.

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Contraceptive Accommodation Choice Enrollment Form

Some employers can object to contraceptive coverage, but the Affordable Care Act says you can ask us to make an exception for you. Use this form to request contraceptive accommodation.

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Blue Care Network Member Reimbursement Form

If you have to pay a provider or hospital for services, this form is how you ask us to reimburse you.

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Blue Care Network Member Billing Form

This form is for bills you receive from providers who don't participate with us. Use it to send us a bill that you haven’t paid.

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Prescription Drug Reimbursement Claim Form

Use these forms if you've paid up front for prescription drugs that your insurance covers and you'd like to be reimbursed.

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Blue Vision Out-of-Network Claim Reimbursement Form

Fill out this form if you need to be reimbursed for payments to an out-of-network Blue Vision provider.

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Essential Vision Out-of-Network Claim Reimbursement Form

Fill out this form if you need to be reimbursed for payments to an out-of-network Essential Vision provider.

Blue Cross Blue Shield of Michigan answers common questions about claims, like how to submit or check the status of a claim, and more. Read about it here.

Managing my account

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Change of Status Form

Use this form to enroll a subscriber in a new plan or make changes to an existing plan, such as adding or removing a dependent.

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Standard Qualification Form

Use this if you have a Blue Cross Blue Shield of Michigan plan that requires a qualification form.

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Blue Care Network Physician Selection Form

If you're a Blue Care Network member, use this form to select or change your doctor.

Blue Cross Blue Shield of Michigan provides information about updating your coverage, requesting your personal records, and paying your bill. Learn more.

Buying health insurance

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2024 Application for Coverage

This application may be used for 2024 individual and family coverage through either Blue Cross Blue Shield of Michigan or Blue Care Network.

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2025 Application for Coverage

This application may be used for 2025 individual and family coverage through either Blue Cross Blue Shield of Michigan (BCBSM) or Blue Care Network of Michigan (BCN), depending on which medical plan you choose. Dental plans, dental with vision, and adult vision plans are only offered through BCBSM, but can be paired with BCBSM or BCN medical plans.

A summary of benefits and coverage from Blue Cross Blue Shield of Michigan or Blue Care Network explains things like what your health plan covers, what it doesn't cover, and what your share of costs will be.

Shopping for health insurance does not have to be difficult. Blue Cross Blue Shield of Michigan explains what to know to make the right choice. Learn more.

Pharmacy

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Prescription Drug Mail Order Form

Use the Optum prescription drug mail order form to get your prescription drugs by mail.

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Specialty Drug Program Pharmacy Benefit Member Guide

Specialty drugs are prescription medications that require special handling, administration or monitoring.

Is your medication covered by your Blue Cross Blue Shield of Michigan health plan? Click on the helpful drug list links to find out.

Do you want more information about your prescription drug plan? Blue Cross Blue Shield of Michigan explains everything you need to know. Learn more here.

Blue Care Network Brochures

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Blue Elect Plus point of service for members

Learn more about the Blue Elect Plus POS and Blue Elect Plus HSA POS health plans.

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Blue Care Network travel brochure

As a Blue Care Network member with BlueCard® coverage, you can receive benefits when you’re away from home, and so can your dependents.

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Blue Elect Plus POS travel brochure

When you’re a Blue Elect Plus POS or Blue Elect Plus HSA POS member, you’re always covered for emergency care while traveling.

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Blue Elect Plus Provider reference card

This tells providers that you’re covered by Blue Elect Plus POS and how they can get information about your coverage.

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BCN HRA℠ HMO member guide

Learn how a health reimbursement arrangement works with your health plan.

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BCN HSA℠ HMO member guide

Learn how a health savings account works with your health plan.

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Healthy Blue Living member guide

Learn how Healthy Blue Living helps you take charge of improving your health.

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Healthy Blue Living weight management program

If your body mass index is 30 or higher, enroll in one of these programs.

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Healthy Blue Choices POS provider reference card

Keep this with your Blue Care Network member ID card, and show it to your doctors and other health care providers when you get care.

Blue Care Network Member FYIs

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Coordinating Blue Care Network health coverage with your car or motorcycle insurance

Learn how we coordinate health coverage with your car or motorcycle insurer.

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Blue Elect Plus Provider reference card

This tells providers that you’re covered by Blue Elect Plus POS and how they can get information about your coverage.

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Coordination of benefits

Learn about Blue Care Network coordination of benefits.

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Making referrals easier to understand for Blue Care Network members in East and Southeast Michigan

As your health care partner, your PCP makes sure you get the care you need when you need it

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Making referrals easier to understand for Blue Care Network members in Mid-, West and Northern Michigan

How referrals work for Blue Care Network members in Mid-, West and Northern Michigan

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Healthy Blue Living member guide

Learn how Healthy Blue Living helps you take charge of improving your health.

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Understanding emergency care coverage and procedures

Here’s what you need to know about emergency care.

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Understanding your Blue Care Network coverage for physical, occupational, speech therapy and physical medicine services

Follow these guidelines for physical, occupational and speech therapy, as well as physical medicine services.

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What if I need durable medical equipment or diabetic supplies?

Learn more about the Blue Care Network policy for getting equipment or supplies.

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Woman's Choice program

For routine women’s health services, you may visit certain Blue Care Network specialists without a referral from your primary care provider.

In Good Health, you'll find plan-related information as well as tips, recipes and articles that can improve your health and well-being.