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
523310 x 13 Envelope with BlueSenior Classic Medicare Supplement plan info on front - not for mailing of Medicare PPO or Rx materials/kits
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
N-11-183 (English)BlueCard Program (for members to locate providers throughout the U.S.)
N-11-183 (Spanish)BlueCard Program (Spanish version for members to locate providers throughout the U.S.)
N-11-187BlueCard Worldwide Program (for members to locate providers around the world)
42-046Summary of Benefits and Coverage postcard
89832-pocket folder: Health Plans for Individuals Under age 65
8909Generic BCBSNE 2-pocket folder
89752-pocket Medicare Supplement folder
4961One Less Thing to Worry About Flyer
92-096High Deductible Health Plans and HSAs - Group (7-11-14 version for 2015)
9017Conversion Coverage Health Care Plan
42-013Open Look under age 65 individual plan performance brochure
36-027Your Guide to Health Care Reform-for brokers and employer-group clients
36-182Health Care Reform: New Benefits, New Costs-for brokers and employer-group clients
36-051-3 (12-4-14)Benefits for Preventive Services (for non-grandfathered groups effective on or after 1-1-15)
36-051-3 (8-25-14)Benefits for Preventive Services (for non-grandfathered groups effective on or after 9-1-14)
36-051-3 (12-23-14)Heath Care Reform Benefits for Preventive Services - Non-Grandfathered
92-109-2 (12-4-14)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
4975In-Network Providers Card
 
     
 
 Applications
IMPORTANT NOTE: Beginning June 1, 2011, a $25 broker fee will be charged for every paper application submitted.
Form NumberForm NameQuantity
3087 rev 10-1-14Application for Individual Coverage (use for 2015 ACA-compliant plans)
3179 (3-13-14)Non-Underwritten Change Application (ACA plans)
3179 (9-1-12)Non-Underwritten Change Application (non-ACA plans)
3062TempCare Application and Contract (Use for 2015 applications)
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
4964Sales and marketing event notification form
31-076TempCare coverage disclaimer
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)
1859Effective Date Form (for new customers only; not transfers between BCBSNE plans/products)
8886Important Information about the Automatic Withdrawal of Your BCBSNE Monthly Premium
3253Medicare Card Form (requests Medicare number and A and B effective dates)
6112Membership Change Request (add newborn, dependent, student information)
3085Non-Tobacco User Certification
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
 
     
 
 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 1001R072015 MedicareBlue Rx pre-enrollment kit (includes formulary and sell sheet)
 
     
 
 Individual DentalEssentials
Form NumberForm NameQuantity
36-141DentalEssentials individual dental brochure
 
     
 
 2015 Individual Benefits Brochures
Form NumberForm NameQuantity
92-133BlueEssentials and SelectBlue benefits brochure (metro area)
92-134BlueEssentials benefits brochure (outside of metro area)
 
     
 
 2014 Individual Benefits Brochures
 
     
 
 Product Brochures -- Under Age 65 Plans
Form NumberForm NameQuantity
92-069TempCare (temporary plans) benefits brochure (2015 plans)
 
     
 
 Product Brochures -- Over Age 65 Plans
Form NumberForm NameQuantity
9135 rev. 11-1-14BlueSenior Classic Medicare Supplement customer brochure. Use when selling 2015 plans
CMS Pub. 02110Choosing a Medigap Policy: A Guide to Health Insurance for People with Medicare (CMS publication for use with Med Supp sales)
36-013Plan L promotional flyer
RAS1005R072015 How Medicare Works booklet
 
     
 
 Rate Books
Form NumberForm NameQuantity
36-1912015 Individual Monthly Plan Rates book - On and Off Exchange Plans
36-211 (12-22-14)2015 TempCare Rate Sheet
 
     
 
 Outlines of Coverage
Form NumberForm NameQuantity
9175 rev. 2-1-15BlueSenior Classic Medicare Supplement Plans. Use when selling 2015 plans
 
     
 
 Manuals
Form NumberForm NameQuantity
4962 PRINTGroup Administration Manual (for groups under our New Claims and Membership System)
4962 CDGroup Administration Manual (for groups under our New Claims and Membership System)
 
     
 
 PremierBlue (health plans for employer groups with 100+ eligible employees)
Form NumberForm NameQuantity
92-106PremierBlue Brochure
 
     
 
 BlueFreedom (health plans for employer groups of 51-99 employees)
Form NumberForm NameQuantity
36-195 (8-14-14)BlueFreedom Plan Options brochure (2015 effective dates)
 
     
 
 BluePride (health plans for employer groups of 2-50 employees)
Form NumberForm NameQuantity
4727BluePride benefits brochure (Pre-ACA/Keep Your Plan))
4728BluePride Options at a Glance (Pre-ACA/Keep Your Plan)
30-009-06BluePride Master Group Application (Pre-ACA/Keep Your Plan)
31-046BluePride Employee Enrollment Form (Pre-ACA/Keep Your Plan)
31-046-01BluePride Employee Enrollment Form (for groups effective 1-1-2014 and after)
36-186 (8-4-14)BluePride Plan Options brochure (ACA)
30-034 (1-1-14)BluePride Master Group Application (ACA)
36-2421st and 2nd Quarter 2015 Rate Book
 
     
 
 Group Three-Tier Health Plan Options
Form NumberForm NameQuantity
36-147Small Group Three-Tier Plan Options – for brokers/group leaders (Pre-ACA/Keep Your Plan for groups of 2-50)
36-180SelectBlue Large Group Three-Tier Plan Options – for brokers/group leaders (effective 1/1/14 for employer groups of 100+)
36-208-1Three-Tier Member FAQs and How to Search for In-Network Providers (for employer groups of 2+ who do not cross accumulate)
36-208-3Three-Tier Member FAQs and How to Search for In-Network Providers (for employer groups of 2+ who cross accumulate)
36-185SelectBlue Plan Options brochure (ACA Plan for groups of 2-50)
36-198SelectBlue Plan Options brochure (for groups of 51-99)
 
     
 
 Self-Funded Employer Group Health Plan Option
Form NumberForm NameQuantity
92-152Self-Funded Employer Group Health Plan Option Brochure
 
     
 
 SignatureBlue (dental plans for employer groups of 2+)
Form NumberForm NameQuantity
36-029SignatureBlue Dental Brochure
 
     
 
 Discount Programs
Form NumberForm NameQuantity
36-050Blue365 discount program flier for all audiences
36-117Individual hearing and vision discount programs flyer
 
     
 
Can't find a form? Please provide form number: 
 
     
 
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: 7/6/2015
If you’re ready to place your order, please click "Submit"