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Plan Forms

  • PDF

    2023 Blue Medicare HMO Change Enrollment Form

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  • PDF

    2022 Blue Medicare HMO Change Request Form

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  • PDF

    2023 Blue Medicare PPO Change Enrollment Form

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  • PDF

    2022 Blue Medicare PPO Change Request Form

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  • PDF

    2023 Blue Medicare Rx (PDP) Change Application

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  • PDF

    2022 Blue Medicare Rx (PDP) Change Request Form

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  • PDF

    Blue Medicare Advantage HMO Summary of Benefits

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  • PDF

    Blue Medicare Advantage PPO Summary of Benefits

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  • PDF

    Blue Medicare Rx PDP Summary of Benefits

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  • PDF

    Blue Medicare Freedom+ PPO Summary of Benefits

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  • PDF

    Blue Medicare Experience Health Medicare Advantage (HMO) Summary of Benefits

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  • PDF

    Healthy Blue + Medicare (D-SNP) Summary of Benefits

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  • PDF

    2023 EOC Blue Medicare HMO Choice 026

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  • PDF

    2023 EOC Blue Medicare HMO Essential 027

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  • PDF

    2023 EOC Blue Medicare PPO Enhanced 003

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  • PDF

    2023 EOC Blue Medicare PPO Freedom+ 004

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  • PDF

    2023 EOC Enhanced HMO-POS 024

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  • PDF

    2023 EOC PDP Enhanced 004

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  • PDF

    2023 EOC Blue Medical Only HMO-POS 012

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  • PDF

    2023 EOC Blue Medicare Essential Plus HMO-POS 023

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  • PDF

    2023 EOC PDP Standard 002

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  • PDF

    2023 Healthy Blue + Medicare (HMO D-SNP) EOC

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  • PDF

    2022 Blue Medicare HMO Medical Only EOC

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  • PDF

    2022 Blue Medicare HMO Choice EOC

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  • PDF

    2022 Blue Medicare HMO Enhanced EOC

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  • PDF

    2022 Blue Medicare HMO Enhanced EOC 024-002 and 003

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  • PDF

    2022 Blue Medicare HMO Essential Plus 023-001 EOC

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  • PDF

    2022 Blue Medicare HMO Essential Plus 023-002

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  • PDF

    2022 Blue Medicare HMO Essential Plus 023-004 and 005 EOC

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  • PDF

    2022 Blue Medicare PPO Enhanced EOC 003-001

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  • PDF

    2022 Blue Medicare PPO Enhanced EOC 003-002

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  • PDF

    2022 Blue Medicare Rx (PDP) Standard EOC

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  • PDF

    2022 Blue Medicare Rx (PDP) Enhanced EOC

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  • PDF

    2022 Blue Medicare Freedom+ PPO EOC

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  • PDF

    2022 Blue Medicare HMO Essential 027-001 EOC

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  • PDF

    2022 Blue Medicare HMO Essential 027-002 EOC

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  • PDF

    2022 Healthy Blue + Medicare (HMO D-SNP) EOC

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  • PDF

    2023 ANOC Blue Medicare Choice (HMO)

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  • PDF

    2023 ANOC Blue Medicare Enhanced HMO 024-001

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  • PDF

    2023 ANOC Blue Medicare Enhanced HMO 024-002

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  • PDF

    2023 ANOC Blue Medicare Enhanced HMO 024-003

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  • PDF

    2023 ANOC Blue Medicare Medical Only HMO-POS

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  • PDF

    2023 ANOC HMO Essential H3449-027-001

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  • PDF

    2023 ANOC HMO Essential H3449-027-002

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  • PDF

    2023 ANOC HMO Essential H3449-027-002 to 001

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  • PDF

    2023 ANOC HMO Essential Plus H3449-023-001

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  • PDF

    2023 ANOC HMO Essential Plus H3449-023-002

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  • PDF

    2023 ANOC HMO Essential Plus H3449-023-004

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  • PDF

    2023 ANOC HMO Essential Plus H3449-023-004 to 001

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  • PDF

    2023 ANOC HMO Essential Plus H3449-023-005

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  • PDF

    2023 ANOC PDP Enhanced S5540 004

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  • PDF

    2023 ANOC PDP Standard S5540-002

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  • PDF

    2023 ANOC PPO Enhanced 003-001

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  • PDF

    2023 ANOC PPO Enhanced 003-002

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  • PDF

    2023 ANOC Blue Medicare Enhanced HMO 024-003 to 001

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  • PDF

    2023 ANOC Healthy Blue + Medicare (HMO D-SNP)

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  • PDF

    2023 ANOC PPO Freedom+ 004

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  • PDF

    2022 Blue Medicare HMO Medical Only ANOC

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  • PDF

    2022 Blue Medicare HMO Choice ANOC

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  • PDF

    2022 Blue Medicare HMO Essential Plus 023-001 ANOC

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  • PDF

    2022 Blue Medicare HMO Essential Plus 023-002 ANOC

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  • PDF

    2022 Blue Medicare HMO Essential Plus 023-004 ANOC

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  • PDF

    2022 Blue Medicare HMO Essential Plus 023-005 ANOC

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  • PDF

    2022 Blue Medicare HMO Essential Plus 023-004 to 002

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  • PDF

    2022 Blue Medicare HMO Essential Plus 023-005 to 001

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  • PDF

    2022 Blue Medicare HMO Essential Plus 023-005 to 004

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  • PDF

    2022 Blue Medicare HMO Enhanced 024-001 ANOC

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  • PDF

    2022 Blue Medicare HMO Enhanced 024-002 ANOC

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  • PDF

    2022 Blue Medicare HMO Enhanced 024-003 ANOC

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  • PDF

    2022 Blue Medicare HMO Enhanced 024-003 to 002

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  • PDF

    2022 Blue Medicare PPO Enhanced ANOC 003-002

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  • PDF

    2022 Blue Medicare PPO Enhanced 003-001 ANOC

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  • PDF

    2022 Blue Medicare PPO Enhanced 003-002 ANOC

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  • PDF

    2022 Blue Medicare PPO Enhanced 003-002 to 001

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  • PDF

    2022 Blue Medicare Rx (PDP) Standard ANOC

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  • PDF

    2022 Blue Medicare Rx (PDP) Enhanced ANOC

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  • PDF

    2022 Blue Medicare HMO Essential 027-001 ANOC

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  • PDF

    2022 Blue Medicare HMO Essential 027-002 ANOC

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  • PDF

    2022 Healthy Blue + Medicare (HMO D-SNP) ANOC

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  • PDF

    2023 Blue Medicare Advantage Comprehensive - Dental

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  • PDF

    2023 Blue Medicare Advantage Preventive Plus - Dental

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Prescription Drug Forms

  • PDF

    2022 Blue Medicare Rx Standard Prior Authorization (December)

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  • PDF

    2022 Blue Medicare Rx Enhanced Prior Authorization (December)

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  • PDF

    2022 Blue Medicare PPO Employer Group Complete, Blue Medicare Rx Employer Group Complete, Blue Medicare HMO Employer Group Complete Prior Authorization (December)

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  • PDF

    2022 Blue Medicare HMO Employer Group Ideal, Blue Medicare PPO Employer Group Ideal, Blue Medicare Rx Employer Group Ideal Prior Authorization (December)

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  • PDF

    2022 Blue Medicare Choice, Blue Medicare Enhanced, Blue Medicare Essential, Blue Medicare Essential Plus, Blue Medicare PPO Enhanced Prior Authorization (December)

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  • PDF

    2023 Blue Medicare Rx Standard Prior Authorization Criteria December

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  • PDF

    2023 Blue Medicare Rx Enhanced Prior Authorization Criteria December

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  • PDF

    2023 Blue Medicare PPO Employer Group Complete, Blue Medicare Rx Employer Group Complete, Blue Medicare HMO Employer Group Complete Prior Authorization Criteria December

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  • PDF

    2023 Blue Medicare HMO Employer Group MAPD, Blue Medicare PPO Employer Group MAPD Prior Authorization Criteria December

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  • PDF

    2023 Blue Medicare Rx Employer Group HCE Prior Authorization Criteria December

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  • PDF

    2023 Blue Medicare Choice, Blue Medicare Enhanced, Blue Medicare Essential, Blue Medicare Essential Plus, Blue Medicare PPO Enhanced Prior Authorization Criteria December

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  • PDF

    2022 Step Therapy Blue Medicare Rx Standard

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  • PDF

    Step Therapy Blue Medicare Employer Group Complete PPO, HMO, Rx (updated December 2022)

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  • PDF

    Step Therapy Blue Medicare Rx Enhanced, HMO Employer Group Ideal, PPO Employer Group Ideal, Rx Employer Group Ideal, Choice, Enhanced, Essential, Essential Plus, PPO Enhanced (updated August 2022)

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  • PDF

    2023 Blue Medicare Rx Standard Step Therapy Criteria December

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  • PDF

    2023 Blue Medicare Rx Standard Step Therapy Criteria December

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  • PDF

    2023 Blue Medicare PPO Employer Group Complete, Blue Medicare Rx Employer Group Complete, Blue Medicare HMO Employer Group Complete Step Therapy Criteria December

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  • PDF

    2023 Blue Medicare HMO Employer Group MAPD, Blue Medicare PPO Employer Group MAPD Step Therapy Criteria December

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  • PDF

    2023 Blue Medicare Rx Employer Group HCE Step Therapy Criteria December

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  • PDF

    2023 Blue Medicare Choice, Blue Medicare Enhanced, Blue Medicare Essential, Blue Medicare Essential Plus, Blue Medicare PPO Enhanced Step Therapy Criteria December

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General Forms

Proof of Coverage

If your coverage with Blue Cross NC has ended and you need proof of coverage, please call Customer Service number on the back of your Blue Cross NC member ID card. If your coverage is still active, and you need a Certification of Health Insurance Coverage document, please call the Customer Service Number on the back of your Blue Cross NC Blue Medicare Rx ID card.

Member Portal

Blue Connect

Access your benefits anytime, anywhere. With Blue Connect, you can review your plan info, check claims, get a copy of your ID card, and so much more.


Log in to Blue Connect
Healthy Blue + Medicare Member Login