Forms and Policies
Plan Forms and Policies
- 2022 Enrollment Form – Access and Core
- 2022 Low-Income Subsidy Table
- Dental Reimbursement Form
- Out of Network and Emergency Care Policy
- Pay Subscriber Form
- Access PPO Disenrollment Form
- Core HMO Disenrollment Form
Prescription Drug Coverage Forms and Policies
- Medication Therapy Management Program
- Part D Prior Authorization
- Part D Step Therapy
- Part D Coverage Determination and Redetermiation
- 2022 Transition Period Drug Benefits
- Medicare Part B Diabetic Testing Supplies Prescriber Fax Form
- Medicare Drug Claim Form
- Alliance Walgreens RX Home Delivery Registration and Prescription Order Form
- Express Scripts Home Delivery Registration and Prescription Order Form
- Part B Drugs Requiring Prior Authorization
Payment Forms/Assistance
- Automatic Payment Withdrawal ACH Form
- Social Security Deduction Application
- CMS Best Available Evidence Policy
Confidential and Representative Forms and Policies
- 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
Helpful Resources
Have Questions?
Request your Medicare Options Guide
Understanding all the coverage options available may feel confusing. Download information from Blue Cross and Blue Shield of Nebraska about Medicare options, important dates to remember and more.