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2015 Medicare Plan Applications
Plan Application for Region in these Counties
Medicare BlueBasic PPO, Medicare BlueClassic PPO, Medicare BlueSecure PPO, Medicare BlueEnhanced PPO CNY Broome - Cayuga - Chemung - Chenango - Cortland - Jefferson - Lewis - Onondaga - Oswego - St. Lawrence - Schuyler - Steuben - Tioga - Tompkins
Medicare BlueBasic PPO, Medicare BluePlus PPO East Clinton - Delaware - Essex - Franklin - Fulton - Hamilton - Montgomery - Otsego
Medicare Bassett PPO East Delaware - Otsego
Medicare Blue Choice Optimum HMO-POS, Medicare Blue Choice Platinum HMO-POS, Medicare Blue Choice Value HMO, Medicare Blue Choice Value Plus HMO Rochester Livingston - Monroe - Ontario - Seneca - Wayne - Yates
Medicare BlueBasic PPO, Medicare BlueClassic PPO, Medicare BlueSecure PPO, Medicare BlueEnhanced PPO Utica-Rome Herkimer - Madison - Oneida
2015 Option Transfer Forms
Form for Your Region Counties in this Region
CNY PPO Option Transfer Form Broome - Cayuga - Chemung - Chenango - Cortland - Jefferson - Lewis - Onondaga - Oswego - St. Lawrence - Schuyler - Steuben - Tioga - Tompkins
East PPO Option Transfer Form Clinton - Delaware - Essex - Franklin - Fulton - Hamilton - Montgomery - Otsego
East Bassett PPO Option Transfer Form Delaware - Otsego
Rochester HMO Option Transfer Form Livingston - Monroe - Ontario - Seneca - Wayne - Yates
Utica-Rome PPO Option Transfer Form Herkimer - Madison - Oneida
Claim Forms
Other Forms
Excellus BlueCross BlueShield contracts with the Federal Government and is an HMO plan and PPO plan with a Medicare contract. Enrollment in Excellus BlueCross BlueShield depends on contract renewal. Submit a complaint about your Medicare plan at www.Medicare.gov or learn about filing a complaint by contacting the Medicare Ombudsman. Y0028_4113_0 Approved.
This page last updated 10/1/2014.
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