For our members who are in active treatment with a provider who leaves our network, they may be eligible to receive coverage for up to 90 days. Use this form to submit a continuity of care request within 90 days of their continued care needs.
For Dental Blue 65 members, use the Dental Blue 65 Enhanced Dental Benefit Enrollment Form.
Fax this form to our Medicare Pharmacy Operations team at 1-866-463-7700 when a hospice patient has been or may be denied a medication at the pharmacy, or to communicate a beneficiary’s change in hospice status.
Includes Detailed Explanation of Non-coverage form
Includes Detailed Explanation of Non-coverage form
Includes Detailed Explanation of Non-coverage form
Includes Detailed Explanation of Non-coverage form
Use this form to grant Blue Cross and Blue Shield of Massachusetts permission to make a single disclosure of specific information to a specific person when that disclosure is not otherwise allowed by law.
This is a Mass Collaborative form. Note: for contractual changes, please use the appropriate Contract Update form. For more information, go to Maintaining & Changing StatusMaintaining & Changing Status.
