Plan Documents
Below are some useful resources and forms for each of the plan
options.
2027 Plan Documents
- Benefits Comparison Chart (PDF)
-
2027 Plan Information Booklet (PDF)
English | Spanish - 2027 BlueChoice Brochure (PDF)
- Proof of Coverage and Tax Identification Number (TIN) Collection FAQs (PDF)
- Family Eligibility Documents (PDF)
- Medical Policy
- Contraception Coverage (PDF)
- Disputed Claims Process (PDF)
- 2027 Federal Health Benefits Program & Medicare Benefits (PDF)
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.)
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)
2026 Plan Documents
-
2026 Plan Information Booklet (PDF)
English | Spanish - 2026 BlueChoice Brochure (PDF)
- Proof of Coverage and Tax Identification Number (TIN) Collection FAQs (PDF)
- Family Eligibility Documents (PDF)
- Medical Policy
- Contraception Coverage (PDF)
- Disputed Claims Process (PDF)
- 2026 Federal Health Benefits Program & Medicare Benefits (PDF)