Forms and Policies
Plans
- 2025 Enrollment Form
- 2025 Dental Reimbursement Form
- 2025 Medical Claim Reimbursement Form
- Request for Disenrollment Form
- Low-Income Subsidy Information
- Out of Network and Emergency Care Policy
- Medical Prior Authorization Request Form
- International Claims Reimbursement Form
- Medicare Advantage Procedures
- InterQual® Criteria
Prescription Drug
- Part D Coverage Determination and Redetermination
- Medication Therapy Management Program
- Part D Prior Authorization
- Part D Step Therapy
- 2025 Transition Period Drug Benefits
- Medicare Part B Diabetic Testing Supplies Prescriber Fax Form
- Medicare Drug Claim Form
- 2025 Part B Drug Requiring Prior Authorization
- Information on Safe Disposal of Drugs
Payments and Assistance
- Automatic Payment Withdrawal Form
- CMS Best Available Evidence Policy
- Medicare Prescription Payment Plan
Confidential and Representative
- Notice of Privacy Practices
- Appointing a Representative
You may choose someone to act on your behalf in filing a grievance, in requesting a coverage determination, and in requesting a redetermination. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.
- Release of Protected Health Information (PHI)
You may choose someone such as a family member of friend to share your Protected Health Information(PHI) with.
- Filing a Grievance or Complaint
- Rights and Responsibilities When You End Your Plan
- Non-discrimination notice and translation services
- Part C Appeal Request
Health Equity Analysis of Utilization Management Policies and Procedures
Annually Blue Cross and Blue Shield of Nebraska (BCBSNE) conducts a health equity analysis of the use of prior authorization. The focus is on understanding how these policies impact different member groups, particularly those with social risk factors such as Low-Income Subsidy (LIS) status, disability status, and dual eligibility for Medicare and Medicaid.
2024 Results
- Non-LIS and non-dual-eligible BCBSNE members had higher approval rates for both standard and expedited authorizations compared to LIS and dual-eligible members.
- Dual-eligible members faced higher denial rates for standard authorizations compared to other groups but experienced significantly faster review times.
Have Questions?
Request your Medicare Options Guide
Understanding all the coverage options available may feel confusing. Get important details from Blue Cross and Blue Shield of Nebraska about Medicare options and important dates to remember.
833-430-4643 (TTY 711)