Blue Access for Producers

Downloadable Forms for Individual Products


Here are some commonly used forms and documents for conducting business with Blue Cross and Blue Shield of Texas (BCBSTX). The forms below are in portable document format (PDF). To view these files, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader® .

Note: Please provide the Texas Department of Insurance Notice  to your clients at the same time as you provide the Outline of Coverage.

PLEASE READ: Texas Department of Insurance required Disclosure Notice  for all individual HMO Consumer Choice benefit plans issued in Texas.

Current Product Comparison Charts
Combined On and Off Exchange Comparison Charts (English) Combined On and Off Exchange Comparison Charts (Spanish)
2020 Gold Plan Comparison Chart  2020 Gold Plan Comparison Chart 
2020 Silver Plan Comparison Chart  2020 Silver Plan Comparison Chart 
2020 Bronze Plan Comparison Chart  2020 Bronze Plan Comparison Chart 

 

Current Individual Forms and Documents
Stock # / Date Enrollment Forms and Change Forms Texas Form #
745718.1019 2020 Individual Paper Application Checklist  N/A
746129.1019 2020 Individual Paper Application Checklist (Spanish Version)  N/A
57330.1019 Health Application/Change in Coverage  Use this health application for 2020 plans, effective January 1, 2020. UN65-APP-Off-EX 2020
725600.1019 Health Application/Change in Coverage (Spanish Version)  Use this application for 2020 plans, effective January 1, 2020. UN65-APP-Off-EX 2020SP
57784.1019 Dental Application/Change in Coverage   Use this dental application for 2020 plans, effective January 1, 2020. APP-DENT-IND-2020
725603.1019 Dental Application/Change in Coverage (Spanish Version)   Use this application for 2020 plans, effective January 1, 2020. APP-DENT-IND-2020SP
727791.1019 2020 Individual Paper Application Overflow Page   UN65-APP-Off-EX 2020-O
727808.1019 2020 Individual Paper Application Overflow Page (Spanish Version)   UN65-APP-Off-EX 2020SP-O
Stock # / Date Benefit Highlights Forms Texas Form #
N/A Blue Advantage Gold HMO 206 - Three $30 PCP Visits  TX-I-H-CC-SOC-BH-20
N/A Blue Advantage Gold HMO 207  TX-I-H-NCC-SOC-BH-20
N/A Blue Advantage Silver HMO 306  TX-I-H-CC-SOC-BH-20
N/A Blue Advantage Silver HMO 205 - Two $25 PCP Visits  TX-I-H-CC-SOC-BH-20
N/A Blue Advantage Bronze HMO 302  TX-I-H-CC-SOC-BH-20
N/A Blue Advantage Bronze HMO 204 - Two $40 PCP Visits  TX-I-H-CC-SOC-BH-20
N/A Blue Advantage Bronze HMO 301  TX-I-H-CC-SOC-BH-20
N/A Blue Advantage Security HMO 200  TX-I-H-CC-SOC-BH-20
N/A Blue Advantage Plus Gold 203  TX-I-H-CC-SOC-BH-20
N/A Blue Advantage Plus Silver 306  TX-I-H-CC-SOC-BH-20
N/A Blue Advantage Plus Silver 202  TX-I-H-CC-SOC-BH-20
N/A Blue Advantage Plus Bronze 201  TX-I-H-CC-SOC-BH-20
N/A Blue Advantage Plus Bronze 303  TX-I-H-CC-SOC-BH-20
N/A Blue Advantage Plus Bronze 305  TX-I-H-CC-SOC-BH-20
N/A MyBlue Health Gold 403  TX-I-H-CC-SOC-BH-20
N/A MyBlue Health Silver 405  TX-I-H-CC-SOC-BH-20
N/A MyBlue Health Bronze 402  TX-I-H-CC-SOC-BH-20
Stock # / Date Miscellaneous Forms Texas Form #
51436.1018 Auto Bill Pay - Automatic Premium Payment Authorization Agreement  N/A
726685.1018 Automatic Premium Payment Authorization Agreement (Spanish)  N/A
N/A Custodial Parent Affidavit  N/A
748937.0719 Disabled Dependent Authorization Form (for Individual Plans) 
Members with an Individual health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSTX (see address and fax number at the top of the form).
N/A
747142.1018 Responsible Party Form  TX-RPF-2018
Stock # / Date Other Benefit/Plan Information Texas Form #
729761.0719 2020 Sales Brochure  N/A
  2020 Sales Brochure (Spanish)  N/A
Stock # / Date Dental Plan/Benefit Information Texas Form #
725568.0719 2020 Sales Brochure  N/A
  2020 Sales Brochure (Spanish)  N/A
N/A BlueCare Dental 4 Kids 1A  N/A
N/A BlueCare Dental 4 Kids 1B  N/A
N/A BlueCare Dental 1A  N/A
N/A BlueCare Dental 2A  N/A
N/A BlueCare Dental 1B  N/A
Stock # / Date Claim Forms and Order Forms Texas Form #
735026.0915 Medical Claim Form (Domestic) 
Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base.
N/A
731140.0116 Medical Claim Form (Domestic) – Spanish 
Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base.
N/A
N-12-420 Medical Claim Form (International) 
Members should use this BlueCard Worldwide claim form to request reimbursement for health care services obtained when traveling internationally - when outside of the United States or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base.
N/A
3272 TX
01/16
Prescription Drug Claim Form  Members with pharmacy benefits through BCBSTX can use this form to request reimbursement for a prescription drug purchase. The original pharmacy receipt must be submitted with the completed form to Prime Therapeutics, the pharmacy benefits manager. N/A
3208 TX
04/16
PrimeMail Order Form  Members with prescription drug coverage can use this form to mail order new or refill prescription maintenance medication. Mail the completed form to PrimeMail and include the original prescription signed by the prescribing doctor. N/A

 

Pre-ACA Individual Forms and Documents
Stock # / Date Enrollment Forms and Change Forms Texas Form #
41745.0517 Series V Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Saver)  IND-APP/MCF-4REV
41745.0111 Series V Application/Miscellaneous Change Form (PPO Select Blue Advantage/PPO Select Choice/PPO Select Saver) - Spanish Version  IND-APP/MCF-3REV SP
42352.0111 Series V Special Offer Application (PPO Select Blue Advantage/PPO Select Choice/PPO Select Saver)  This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application
IND-APP(SO)-2REV
733084.0117 Application for Transfer of Coverage 
N/A
51164.0217 BlueEdge Individual HSA Application/Miscellaneous Change Form 
BLUE EDGE-IND-HSA-APP/MCF-6REV
51165.0111 BlueEdge Individual HSA Special Offer Application  This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application. BLUE EDGE-IND-HSA-APP(SO)-3REV
42320.0111 Foundation Hospital Care Miscellaneous Change Form  PPO-INHOSPITAL-APP/MCF-2REV
42684.0111 PPO Select Value Care Miscellaneous Change Form  PPO-IND-VALUE-APP/MCF-3REV
41694.0111 PPO Select Basic Miscellaneous Change Form 
PPO-IND-CCHBP-MCF(B)-4REV
43954.0111 MSA Blue Application/Miscellaneous Change Form  IND-CMM-APP/MCF-3REV
43971.0111 Non-Underwritten Changes Miscellaneous Change Form  This form is to be used for effective dates of December 1, 2007 and forward. It replaces the Miscellaneous Change Forms for older Select Products (i.e., PPO Select, PPO Select Advantage and Select 2000) and non-Series III, IV, and V Products (i.e., PPO Select Saver, PPO Select Choice and Select Blue Advantage). Use this form if you want to add dependent(s), cancel coverage or downgrade your benefits. IND-MCF-Non-UW-3
43969.0111 Underwritten Changes Miscellaneous Change Form  This form is to be used for effective dates of December 1, 2007 and forward. It replaces the Miscellaneous Change Forms for older Select Products (i.e., PPO Select, PPO Select Advantage, Select 2000) and non Series III, IV, and V Products (i.e., PPO Select Saver, PPO Select Choice and Select Blue Advantage). Use this form if you want to add dependent(s) or upgrade your benefits. IND-MCF-UW-3REV
Stock # / Date Miscellaneous Forms Texas Form #
752154.1119 Automatic Premium Payment Authorization Agreement  - This form is to be used for pre-ACA plans only. N/A
08.01.15 Standard Authorization Form and other HIPAA Privacy Forms N/A
Stock # / Date Dental Plan Information Texas Form #
40110.404 Dental Indemnity USA Monthly Premium Rate Guide  N/A
0009.374-0908 Dental Indemnity USA Outline of Coverage  IND-DEN-2-OLC-1
N/A Dental Scheduled Benefit Plan - Region II  TXGRGNII
N/A Dental Scheduled Benefit Plan - Region IV  TXGRGNIV
Stock # / Date Other Plan Information Texas Form #
53398.0312 Blue Pathway Sales Flier  N/A
 

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