Marketing Materials Order Form
 
     
 Instructions
  1. Indicate the materials you want to order by completing the “quantity” field. You can search by form name or number by using Ctrl + F.
  2. Proceed to the bottom of the form to enter the required information in the fields below.

    If you experience problems with this form, or have questions about your order, please send an e-mail message to PRODSPT@nebraskablue.com.
     
 
Envelopes
Form NumberForm NameQuantity
70510 x 13 Envelope with Important Plan Information message - must be used when mailing Medicare PPO or Rx materials to prospects and beneficiaries
1898Postage-paid return envelope - Individual Underwriting Department (9 x 4)
1899Postage-paid return envelope - Individual Underwriting Department (6 x 9)
1901Postage-paid return envelope - Individual Underwriting Department (13 x 10)
 
     
 
Miscellaneous
Form NumberForm NameQuantity
36-317BlueCard/Blue Cross Blue Shield Global Core Member Flier (for members to locate in-network providers in the U.S. and worldwide)
42-046Summary of Benefits and Coverage Card
89832-pocket folder: Health Plans for Individuals Under age 65
8909Generic BCBSNE 2-pocket folder
89752-pocket Medicare Supplement folder
92-096 (08-19-16)High Deductible Health Plans and HSAs - Group (for 2017)
42-013Open Look under age 65 individual plan performance brochure
36-051-3 (07-18-16)Health Care Reform Benefits for Preventive Services (Non-grandfathered plans eff 06-01-16)
36-051-3 (10-03-16)Health Care Reform Benefits for Preventive Services (Non-grandfathered plans eff 08-01-16)
36-051-3 (10-12-16)Health Care Reform Benefits for Preventive Services (Non-grandfathered plans eff 01-01-17)
36-051-3 (05-25-17)Health Care Reform Benefits for Preventive Services (Non-grandfathered plans eff 07-01-17)
36-051-3 (06-01-17)Health Care Reform Benefits for Preventive Services (Non-grandfathered plans eff 12-01-17)
92-109-2 (12-04-14)Preventive Health Guidelines (for non-grandfathered plans effective on or after 1-1-15)
92-109 (3-26-14)Preventive Health Guidelines (for grandfathered plans)
36-100Online Tools and Resources from BCBSNE (for members who have Prime for their pharmacy benefits manager)
36-100-1Online Tools and Resources from BCBSNE (for members who do not have Prime for their pharmacy benefits manager)
4975In-Network Providers Card
92-163 (12-05-16)Your Quick Guide to BCBSNE's Network Options
 
     
 
 Applications
IMPORTANT NOTE: Beginning June 1, 2011, a $25 broker fee will be charged for every paper application submitted.
Form NumberForm NameQuantity
3087 (6-9-17)Individual Product Enrollment Form (2017)
31-095DentalEssentials stand-alone application
3041Medicare Supplement with optional DentalEssentials application
 
     
 
Directories
Form NumberForm NameQuantity
36-066NEtwork BLUE Directory
 
     
 
 Forms
Form NumberForm NameQuantity
Y0052Medicare Scope of Appointment Form
50-033-1 (06-15-17)Medicare Supplement Agent of Record Change Request Form
4964-01Sales and marketing event notification form
36-002Application reporting form
8664-4Authorization for Release of Protected Health Information
5925Cancellation request
3632Carve out form (pending application) (also known as a Bank Depositor Form – use when additional information is needed before an application/change can be processed)
3117Certification of Non-Applicability of the Health Insurance Portability And Accountability Act (HIPAA)
8682Consumer Insurance Disclosure
3228Dependency Statement (use to certify and list eligible dependents)
8886Important Information about the Automatic Withdrawal of Your BCBSNE Monthly Premium
3253Medicare Card Form (requests Medicare number and A and B effective dates)
3205Notice to Applicant Regarding Replacement of Medicare Supplement Insurance or Medicare Advantage
PRI-2296Patient Medication List Drug Formulary (Prime Therapeutics)
1896Preferred premium discount medical questionnaire
3640Reinstatement request
9071Rx Nebraska Prescription Drug Benefits
6177Subscriber's claim form
50-101Nondiscrimination Notice and Meaningful Access form
 
     
 
 MedicareBlue Rx Products
Available to Medicare-Certified Agents & Brokers Only
 
BCBSNE will not send the following MedicareBlue PPO and/or MedicareBlue Rx marketing materials to agents who are not certified to sell Medicare products. Please check the box below to verify you have completed both the AHIP training and the product training to become Medicare certified.

I verify that I am currently certified to sell MedicareBlue products. I understand that selling MedicareBlue products without being certified can result in loss of my sales appointment.
 
Form NumberForm NameQuantity
RAS 1001R092017 MedicareBlue Rx pre-enrollment kit (includes formulary and sell sheet)
 
     
 
 Individual DentalEssentials
Form NumberForm NameQuantity
36-141DentalEssentials individual dental brochure
 
     
 
 Individual Benefits Brochures
Form NumberForm NameQuantity
92-133 (11-15-16)2017 BlueEssentials and SelectBlue benefits brochure (Area 2 683-685)
92-134 (11-15-16)2017 BlueEssentials benefits brochure (Areas 3 and 4 686-693)
92-165 (11-15-16)2017 Select Blue benefits brochure (Area 1 680-681)
 
     
 
 Product Brochures -- Under Age 65 Plans
 
     
 
 Product Brochures -- Over Age 65 Plans
Form NumberForm NameQuantity
CMS Pub. 02110Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare (CMS publication for use with Med Supp sales)
RAS1005R092017 How Medicare Works booklet 12/16
 
     
 
 Rate Books
Form NumberForm NameQuantity
36-191 (10-17-16)2017 Individual Monthly Plan Rate Book
 
     
 
 Outlines of Coverage
Form NumberForm NameQuantity
9175 rev. 01-09-17Medicare Supplement Plans. Use when selling 2017 plans. Rates effective April 1, 2017 through March 31, 2018
 
     
 
 Manuals
 
     
 
 PremierBlue (health plans for employer groups with 151 + eligible employees)
Form NumberForm NameQuantity
92-106Large Group Sales Brochure – Premier Blue/Select Blue
 
     
 
 BlueFreedom (health plans for employer groups with 51-150 eligible employees)
Form NumberForm NameQuantity
36-195 (09-22-16)SelectBlue and BlueFreedom Plan Options Brochure (2017)
30-015BlueFreedom Master Group Application
31-072BlueFreedom Employee Enrollment Form
 
     
 
 BluePride (health plans for employer groups of 1-50 employees)
Form NumberForm NameQuantity
4727BluePride benefits brochure (Pre-ACA/Keep Your Plan))
4728BluePride Options at a Glance (Pre-ACA/Keep Your Plan)
31-046BluePride Employee Enrollment Form (Pre-ACA/Keep Your Plan)
30-034BluePride Master Group Application (ACA)
36-186 (11-11-16)Select Blue and BluePride Plan Options (2017)
36-242 (10-12-16)2017 Rate Book
 
     
 
 Group Three-Tier Health Plan Options
Form NumberForm NameQuantity
36-180Select Blue / Three-Tier Plan Options – for brokers/group leaders (effective 1/1/16 for employer groups of (101+)
36-208-1 (03-15-17)Three-Tier Important Info Member Flier (for customer three-tier groups who do not cross accumulate)
36-208-3Three-Tier Important Info Member Flier (for customer three-tier groups who do cross accumulate)
36-208-6Three-Tier Important Info Member Flier (for customer three-tier groups who do not cross accumulate and CHI is in-network)
36-208-7Three-Tier Important Info Member Flier (for customer three-tier groups who do cross accumulate and CHI is in-network)
 
     
 
 Self-Funded Employer Group Health Plan Option
 
     
 
 SignatureBlue (dental plans for employer groups of 2+)
Form NumberForm NameQuantity
36-029SignatureBlue Dental Brochure – for brokers/group leaders
 
     
 
ID Protection
Form NumberForm NameQuantity
36-275AllClear ID Broker/Group Leader Flier
 
     
 
Telehealth
Form NumberForm NameQuantity
92-160Telehealth Group Sales Brochure – Brokers/Group Leader
36-260Telehealth Quick Start Guide – Brokers/Group Leader
 
     
 
 Discount Programs
Form NumberForm NameQuantity
36-050Blue365 Member Flier
92-147Blue365 Group Discount Program – Leader/Member Flier
 
     
 
Can't find a form? Please provide form number: 
 
     
 
Nondiscrimination Notices and Language must be provided with each document requiring a signature from the qualified individual, applicant or enrollee.
Note: All information is required in order for processing
Name:  
Company:  
Address:
Please note: We cannot ship to a PO Box.
City, State, Zip:
Phone Number:  
E-mail:  
Date: 7/28/2017
If you’re ready to place your order, please click "Submit"