Forms and Information
Member
Forms
- Claim Form (paper)
- Claim Form Online Submission (international claims excluded)
- International Claim Form
- Fitness Reimbursement Form*
- Weight Loss Reimbursement Form*
- Childbirth Classes Claim Form*
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Claim Summary Example
How to read a Summary of Health Plan Payments for medical services you’ve received.
*With the MyBlue App you can file for reimbursement online.
Miscellaneous Forms
- Cost Estimate Checklist
- 1099 HC Form
- Appeals & Grievances
- Continuity of Care Request Form (if your doctor is leaving our network)
- Transition of Care for New Members (new members with out-of-network providers)
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Travel Benefit Reimbursement Form
- Under the medical benefits travel rider, Blue Cross Blue Shield of Massachusetts will reimburse members for certain expenses related to travel to obtain covered services other than routine or preventative care when access to those services is not available within 100 miles of the member’s home and the member must travel to obtain the services.
At-Home Test Forms
Kits must be FDA-approved. Reimbursement for up to eight at-home FDA-approved COVID test kits each per 30-day period. Limitations apply. Learn more about covid-19 benefits and reimbursement.
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BCBS COVID-19 At-Home Test Kits Reimbursement Form
(for kits purchased January 15, 2022, through February 4, 2022) -
Express Scripts Covid-19 Home Test Kits Reimbursement Form
(for kits purchased on or after February 4, 2022)
If your purchase was at a non-ESI pharmacy or paid via the regular checkout lane, you can submit your receipts for reimbursement - up to $12 per test ($24 per two-pack).