Resources & Forms
Below are some useful resources and forms for each of the plan options.
2023 Plan Documents
2024 Plan Documents
- Benefits Comparison Chart (PDF)
- Federal Health Benefits Program & Medicare Benefits (PDF)
- 2024 BlueChoice Brochure (PDF)
- 2024 Plan Information Booklet (PDF) English | Spanish
- Proof of Coverage and Tax Identification Number (TIN) Collection FAQs (PDF)
- Family Eligibility Documents (PDF)
- Medical Policy
- Contraception Coverage (PDF)
2023 Summaries of Benefits and Coverage (SBCs)
2024 Summaries of Benefits and Coverage (SBCs)
2024 BlueChoice Advantage HDHP Forms
- Add a Dependent Form (PDF)
- Coordination of Benefits (PDF)
- HSA/HRA Selection Form (PDF)
- Medical Claim Form (PDF)
- Prescription Mail Order Form (PDF)
- Prescription Reimbursement Claim Form (PDF)
- Social Security Number Submission Form (PDF)
- Vision Claim Form - Davis (PDF)
- International Claim Form (PDF)
(for members receiving care outside of the U.S.)
2024 Blue Value Plus Forms
2024 Standard BlueChoice Forms
- Add a Dependent Form (PDF)
- Coordination of Benefits (PDF)
- Medical Claim Form (PDF)
- Prescription Mail Order Form (PDF)
- Prescription Reimbursement Claim Form (PDF)
- Social Security Number Submission Form (PDF)
- Vision Claim Form - Davis (PDF)
- International Claim Form (PDF)
(for members receiving care outside of the U.S)