For Employers
ENROLLMENT FORM
Use this form to enroll eligible new employees, current employees who become
eligible based on hours worked, or current eligible employees who previously
waived and have either a HIPAA qualifying special event or open enrollment.
CHANGE FORM
This form to make changes to current employee coverages such as enroll a newborn,
drop a spouse, or change an address.
WAIVE FORM
Use this form to keep a record of all eligible employees who choose to waive group coverage.
AFFIDAVIT OF DOMESTIC PARTNERSHIP
Use this form to submit verification of a domestic partner.
HPMPT WELLNESS FORM
Use this form to participate in the Wellness Program.
For Employees
BCBSMT MEDICAL CLAIM FORM Use this form for reimbursement of medical claims paid.
BCBS/PRIME PHARMACY CLAIM FORM (for prescriptions on or after 01/01/2023) Use one of the forms listed below for reimbursement of pharmacy claims paid, or Mail Order prescriptions:
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Use this form for reimbursement of Rx claims. BCBS Form
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Use this form for Mail order from Express Scripts. Express Scripts Form
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Use this form for Mail order from Ridgeway. Ridgeway Form
INTERNATIONAL TRAVEL INFORMATION This flyer provides information that the member can take while living or traveling abroad.
INTERNATIONAL CLAIM FORM Use this form to file an international claim.
DENTAL CLAIM FORM Use this form for reimbursement of dental claims.
VISION CLAIM FORM Use this form for reimbursement of vision claims.