Forms and Policies
Plan Forms and Policies
- 2019 Enrollment Form
- 2019 Low-Income Subsidy Table
- 2020 Enrollment Form
- 2020 Low-Income Subsidy Table
- Dental Reimbursement Form
- Out of Network and Emergency Care Policy
Prescription Drug Coverage Forms and Policies
- Medication Therapy Management Program
- Part D Prior Authorization
- Part D Step Therapy
- Part D Coverage Determination and Redetermiation
- 2019 Transition Period Drug Benefits
- 2020 Transition Period Drug Benefits
Payment Forms/Assistance
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?
Getting Started?
Toll Free: 833-430-4643
(TTY 711)
Toll Free: 833-430-4643
(TTY 711)
Already a Member?
Toll Free: 888-488-9850
(TTY 711)
Toll Free: 888-488-9850
(TTY 711)
Request your Medicare Options Guide
Understanding all the coverage options available may feel confusing. Download our Blue Cross and Blue Shield of Nebraska Medicare options guide to review different products that are available and learn more about important dates to remember.