Downloadable Forms for Individual Products
Here are some commonly used forms and documents for conducting business with Blue Cross and Blue Shield of Texas (BCBSTX). The forms below are in portable document format (PDF). To view these files, you may need to install a PDF reader program. Most PDF readers are a free download. One option is Adobe® Reader® 
.
Note: Please provide the Texas Department of Insurance Notice 
to your clients at the same time as you provide the Outline of Coverage.
PLEASE READ: Texas Department of Insurance required Disclosure Notice for all individual HMO Consumer Choice benefit plans issued in Texas.
| Current Product Comparison Charts | |
| Combined On and Off Exchange Comparison Charts (English) | Combined On and Off Exchange Comparison Charts (Spanish) |
| 2021 Gold Plan Comparison Chart |
2021 Gold Plan Comparison Chart |
| 2021 Silver Plan Comparison Chart |
2021 Silver Plan Comparison Chart |
| 2021 Bronze Plan Comparison Chart |
2021 Bronze Plan Comparison Chart |
| 2022 Gold Plan Comparison Chart |
2022 Gold Plan Comparison Chart |
| 2022 Silver Plan Comparison Chart |
2022 Silver Plan Comparison Chart |
| 2022 Bronze Plan Comparison Chart |
2022 Bronze Plan Comparison Chart |
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Current Individual Forms and Documents
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| Stock # / Date | Enrollment Forms and Change Forms | Texas Form # | |
| 745718.1020 | 2021 Individual Paper Application Checklist |
N/A | |
| 746129.1020 | 2021 Individual Paper Application Checklist (Spanish Version) |
N/A | |
| 57330.1020 | Health Application/Change in Coverage Use this health application for 2021 plans, effective January 1, 2021. |
UN65-APP-Off-EX-2021-1 | |
| 725600.1020 | Health Application/Change in Coverage (Spanish Version) Use this application for 2021 plans, effective January 1, 2021 |
UN65-APP-Off-EX-2021-1SP | |
| 57784.1020 | Dental Application/Change in Coverage Use this dental application for 2021 plans, effective January 1, 2021. |
APP-DENT-IND-2021-1 | |
| 725603.1020 | Dental Application/Change in Coverage (Spanish Version) Use this application for 2021 plans, effective January 1, 2021. |
APP-DENT-IND-2021-1SP | |
| 727791.1020 | 2021 Individual Paper Application Overflow Page |
UN65-APP-Off-EX-2021-O | |
| 727808.1020 | 2021 Individual Paper Application Overflow Page (Spanish Version) |
UN65-APP-Off-EX-2021SP-O | |
| Stock # / Date | Enrollment Forms and Change Forms | Texas Form # | |
| TBA | 2022 Individual Paper Application Checklist |
N/A | |
| TBA | 2022 Individual Paper Application Checklist (Spanish Version) |
N/A | |
| TBA | Health Application/Change in Coverage Use this health application for 2022 plans, effective January 1, 2022. |
TBA | |
| TBA | Health Application/Change in Coverage (Spanish Version) Use this application for 2022 plans, effective January 1, 2022. |
TBA | |
| TBA | Dental Application/Change in Coverage Use this dental application for 2022 plans, effective January 1, 2022. |
TBA | |
| TBA | Dental Application/Change in Coverage (Spanish Version) Use this application for 2022 plans, effective January 1, 2022. |
TBA | |
| TBA | 2022 Individual Paper Application Overflow Page |
TBA | |
| TBA | 2022 Individual Paper Application Overflow Page (Spanish Version) |
TBA | |
| Stock # / Date | Benefit Highlights Forms | Texas Form # | |
| N/A | Blue Advantage Gold HMO 206 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | Blue Advantage Gold HMO 207 |
TX-I-H-NCC-SOC-BH-21 | |
| N/A | Blue Advantage Silver HMO 306 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | Blue Advantage Silver HMO 205 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | Blue Advantage Bronze HMO 302 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | Blue Advantage Bronze HMO 204 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | Blue Advantage Bronze HMO 301 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | Blue Advantage Security HMO 200 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | Blue Advantage Plus Gold 203 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | Blue Advantage Plus Silver 306 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | Blue Advantage Plus Silver 202 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | Blue Advantage Plus Bronze 201 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | Blue Advantage Plus Bronze 303 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | Blue Advantage Plus Bronze 305 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | Blue Advantage Plus Bronze 501 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | MyBlue Health Gold 403 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | MyBlue Health Silver 405 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | MyBlue Health Bronze 402 |
TX-I-H-CC-SOC-BH-21 | |
| N/A | Blue Advantage Gold HMO 206 |
TBA | |
| N/A | Blue Advantage Gold HMO 207 |
TBA | |
| N/A | Blue Advantage Silver HMO 306 |
TBA | |
| N/A | Blue Advantage Silver HMO 205 |
TBA | |
| N/A | Blue Advantage Bronze HMO 302 |
TBA | |
| N/A | Blue Advantage Bronze HMO 204 |
TBA | |
| N/A | Blue Advantage Bronze HMO 301 |
TBA | |
| N/A | Blue Advantage Security HMO 200 |
TBA | |
| N/A | Blue Advantage Plus Gold 203 |
TBA | |
| N/A | Blue Advantage Plus Silver 306 |
TBA | |
| N/A | Blue Advantage Plus Silver 202 |
TBA | |
| N/A | Blue Advantage Plus Bronze 201 |
TBA | |
| N/A | Blue Advantage Plus Bronze 303 |
TBA | |
| N/A | Blue Advantage Plus Bronze 305 |
TBA | |
| N/A | Blue Advantage Plus Bronze 501 |
TBA | |
| N/A | MyBlue Health Gold 403 |
TBA | |
| N/A | MyBlue Health Silver 405 |
TBA | |
| N/A | MyBlue Health Bronze 402 |
TBA | |
| N/A | Blue Advantage Plus Silver 605 |
TBA | |
| N/A | Blue Advantage Gold HMO 603 |
TBA | |
| N/A | Blue Advantage Silver HMO 601 |
TBA | |
| Stock # / Date | Miscellaneous Forms | Texas Form # | |
| 51436.1018 | Auto Bill Pay - Automatic Premium Payment Authorization Agreement |
N/A | |
| 726685.1018 | Automatic Premium Payment Authorization Agreement (Spanish) |
N/A | |
| N/A | Custodial Parent Affidavit |
N/A | |
| 748937.0719 | Disabled Dependent Authorization Form (for Individual Plans) Members with an Individual health plan should use this form to request continuation of coverage on their existing policy for a dependent who is incapable of self-support because of mental or physical impairment. Mail or fax the completed form to BCBSTX (see address and fax number at the top of the form). |
N/A | |
| 747142.1018 | Responsible Party Form |
TX-RPF-2018 | |
| Stock # / Date | Other Benefit/Plan Information | Texas Form # | |
| 729761.1020 | 2021 Sales Brochure |
N/A | |
| 725872.1020 | 2021 Sales Brochure (Spanish) |
N/A | |
| TBA | 2022 Sales Brochure |
N/A | |
| TBA | 2022 Sales Brochure (Spanish) |
N/A | |
| Stock # / Date | Dental Plan/Benefit Information | Texas Form # | |
| 725568.0820 | 2021 BlueCare Dental Flier |
N/A | |
| 726267.0820 | 2021 BlueCare Dental Flier (Spanish Version) |
N/A | |
| N/A | BlueCare Dental 4 Kids 1A |
TX-I-D-OOC-4K-1A-2021 | |
| N/A | BlueCare Dental 4 Kids 1B |
TX-I-D-OOC-4K-1B-2021 | |
| N/A | BlueCare Dental 1A |
TX-I-D-OOC-1A-2021 | |
| N/A | BlueCare Dental 2A |
TX-I-D-OOC-2A-2021 | |
| N/A | BlueCare Dental 1B |
TX-I-D-OOC-1B-2021 | |
| TBA | 2022 Sales Brochure |
N/A | |
| TBA | 2022 Sales Brochure (Spanish) |
N/A | |
| N/A | BlueCare Dental 4 Kids 1A |
N/A | |
| N/A | BlueCare Dental 4 Kids 1B |
N/A | |
| N/A | BlueCare Dental 1A |
N/A | |
| N/A | BlueCare Dental 2A |
N/A | |
| N/A | BlueCare Dental 1B |
N/A | |
| Stock # / Date | Claim Forms and Order Forms | Texas Form # | |
| 735026.0915 | Medical Claim Form (Domestic) Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base. |
N/A | |
| 731140.0116 | Medical Claim Form (Domestic) – Spanish Members should use this form to request reimbursement for health care services obtained within the United States, a U.S. territory, when on a cruise ship, or on a U.S. military base. |
N/A | |
| N-12-420 | Medical Claim Form (International) Members should use this BlueCard Worldwide claim form to request reimbursement for health care services obtained when traveling internationally - when outside of the United States or a U.S. territory, but NOT for services obtained on a cruise ship or a U.S. military base. |
N/A | |
| 3272 TX 01/16 |
Prescription Drug Claim Form Members with pharmacy benefits through BCBSTX can use this form to request reimbursement for a prescription drug purchase. The original pharmacy receipt must be submitted with the completed form to Prime Therapeutics, the pharmacy benefits manager. |
N/A | |
| 3208 TX 04/16 |
PrimeMail Order Form Members with prescription drug coverage can use this form to mail order new or refill prescription maintenance medication. Mail the completed form to PrimeMail and include the original prescription signed by the prescribing doctor. |
N/A | |
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Pre-ACA Individual Forms and Documents
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| Stock # / Date | Enrollment Forms and Change Forms | Texas Form # |
| 41745.0517 | Series V Application/Miscellaneous Change Form (Select Blue Advantage/PPO Select Choice/PPO Select Saver) |
IND-APP/MCF-4REV |
| 41745.0111 | Series V Application/Miscellaneous Change Form (PPO Select Blue Advantage/PPO Select Choice/PPO Select Saver) - Spanish Version |
IND-APP/MCF-3REV SP |
| 42352.0111 | Series V Special Offer Application (PPO Select Blue Advantage/PPO Select Choice/PPO Select Saver) This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application |
IND-APP(SO)-2REV |
| 733084.0117 | Application for Transfer of Coverage |
N/A |
| 51164.0217 | BlueEdge Individual HSA Application/Miscellaneous Change Form |
BLUE EDGE-IND-HSA-APP/MCF-6REV |
| 51165.0111 | BlueEdge Individual HSA Special Offer Application This application is intended for renewal policies only. Verification of qualification should be made prior to filling out this application. |
BLUE EDGE-IND-HSA-APP(SO)-3REV |
| 42320.0111 | Foundation Hospital Care Miscellaneous Change Form |
PPO-INHOSPITAL-APP/MCF-2REV |
| 42684.0111 | PPO Select Value Care Miscellaneous Change Form |
PPO-IND-VALUE-APP/MCF-3REV |
| 41694.0111 | PPO Select Basic Miscellaneous Change Form |
PPO-IND-CCHBP-MCF(B)-4REV |
| 43954.0111 | MSA Blue Application/Miscellaneous Change Form |
IND-CMM-APP/MCF-3REV |
| 43971.0111 | Non-Underwritten Changes Miscellaneous Change Form This form is to be used for effective dates of December 1, 2007 and forward. It replaces the Miscellaneous Change Forms for older Select Products (i.e., PPO Select, PPO Select Advantage and Select 2000) and non-Series III, IV, and V Products (i.e., PPO Select Saver, PPO Select Choice and Select Blue Advantage). Use this form if you want to add dependent(s), cancel coverage or downgrade your benefits. |
IND-MCF-Non-UW-3 |
| 43969.0111 | Underwritten Changes Miscellaneous Change Form This form is to be used for effective dates of December 1, 2007 and forward. It replaces the Miscellaneous Change Forms for older Select Products (i.e., PPO Select, PPO Select Advantage, Select 2000) and non Series III, IV, and V Products (i.e., PPO Select Saver, PPO Select Choice and Select Blue Advantage). Use this form if you want to add dependent(s) or upgrade your benefits. |
IND-MCF-UW-3REV |
| Stock # / Date | Miscellaneous Forms | Texas Form # |
| 752154.1119 | Automatic Premium Payment Authorization Agreement - This form is to be used for pre-ACA plans only. |
N/A |
| 08.01.15 | Standard Authorization Form and other HIPAA Privacy Forms | N/A |
| Stock # / Date | Dental Plan Information | Texas Form # |
| 40110.404 | Dental Indemnity USA Monthly Premium Rate Guide |
N/A |
| 0009.374-0908 | Dental Indemnity USA Outline of Coverage |
IND-DEN-2-OLC-1 |
| N/A | Dental Scheduled Benefit Plan - Region II |
TXGRGNII |
| N/A | Dental Scheduled Benefit Plan - Region IV |
TXGRGNIV |
| Stock # / Date | Other Plan Information | Texas Form # |
