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Plan Forms
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2023 Blue Medicare HMO Change Enrollment Form
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2022 Blue Medicare HMO Change Request Form
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2023 Blue Medicare PPO Change Enrollment Form
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2022 Blue Medicare PPO Change Request Form
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2023 Blue Medicare Rx (PDP) Change Application
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2022 Blue Medicare Rx (PDP) Change Request Form
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Blue Medicare Advantage HMO Summary of Benefits
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Blue Medicare Advantage PPO Summary of Benefits
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Blue Medicare Rx PDP Summary of Benefits
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Blue Medicare Freedom+ PPO Summary of Benefits
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Blue Medicare Experience Health Medicare Advantage (HMO) Summary of Benefits
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Healthy Blue + Medicare (D-SNP) Summary of Benefits
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2023 EOC Blue Medicare HMO Choice 026
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2023 EOC Blue Medicare HMO Essential 027
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2023 EOC Blue Medicare PPO Enhanced 003
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2023 EOC Blue Medicare PPO Freedom+ 004
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2023 EOC Enhanced HMO-POS 024
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2023 EOC PDP Enhanced 004
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2023 EOC Blue Medical Only HMO-POS 012
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2023 EOC Blue Medicare Essential Plus HMO-POS 023
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2023 EOC PDP Standard 002
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2023 Healthy Blue + Medicare (HMO D-SNP) EOC
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2023 ANOC Blue Medicare Choice (HMO)
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2023 ANOC Blue Medicare Enhanced HMO 024-001
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2023 ANOC Blue Medicare Enhanced HMO 024-002
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2023 ANOC Blue Medicare Enhanced HMO 024-003
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2023 ANOC Blue Medicare Medical Only HMO-POS
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2023 ANOC HMO Essential H3449-027-001
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2023 ANOC HMO Essential H3449-027-002
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2023 ANOC HMO Essential H3449-027-002 to 001
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2023 ANOC HMO Essential Plus H3449-023-001
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2023 ANOC HMO Essential Plus H3449-023-002
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2023 ANOC HMO Essential Plus H3449-023-004
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2023 ANOC HMO Essential Plus H3449-023-004 to 001
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2023 ANOC HMO Essential Plus H3449-023-005
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2023 ANOC PDP Enhanced S5540 004
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2023 ANOC PDP Standard S5540-002
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2023 ANOC PPO Enhanced 003-001
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2023 ANOC PPO Enhanced 003-002
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2023 ANOC Blue Medicare Enhanced HMO 024-003 to 001
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2023 ANOC Healthy Blue + Medicare (HMO D-SNP)
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2023 ANOC PPO Freedom+ 004
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2023 Blue Medicare HMO Star Ratings
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2023 Blue Medicare PPO Star Ratings
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2023 Blue Medicare Rx Star Ratings
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2023 Medicare DSNP Star Ratings
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2022 Blue Medicare HMO Star Ratings
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2022 Blue Medicare PPO Star Ratings
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2022 Healthy Blue + Medicare Star Ratings
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2022 Blue Medicare Rx Star Ratings
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Prescription Drug Forms
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2023 Blue Medicare Rx Standard Prior Authorization Criteria (February)
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2023 Blue Medicare Rx Enhanced Prior Authorization Criteria February
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2023 Blue Medicare PPO Employer Group Complete, Blue Medicare Rx Employer Group Complete, Blue Medicare HMO Employer Group Complete Prior Authorization Criteria (February)
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2023 Blue Medicare HMO Employer Group MAPD, Blue Medicare PPO Employer Group MAPD Prior Authorization Criteria (February)
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2023 Blue Medicare Rx Employer Group HCE Prior Authorization Criteria (February)
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2023 Blue Medicare Choice, Blue Medicare Enhanced, Blue Medicare Essential, Blue Medicare Essential Plus, Blue Medicare PPO Enhanced Prior Authorization Criteria (February)
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2023 Blue Medicare Rx Standard Step Therapy Criteria (January)
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2023 Blue Medicare Rx Standard Step Therapy Criteria (January)
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2023 Blue Medicare PPO Employer Group Complete, Blue Medicare Rx Employer Group Complete, Blue Medicare HMO Employer Group Complete Step Therapy Criteria (January)
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2023 Blue Medicare HMO Employer Group MAPD, Blue Medicare PPO Employer Group MAPD Step Therapy Criteria (January)
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2023 Blue Medicare Rx Employer Group HCE Step Therapy Criteria (January)
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2023 Blue Medicare Choice, Blue Medicare Enhanced, Blue Medicare Essential, Blue Medicare Essential Plus, Blue Medicare PPO Enhanced Step Therapy Criteria (January)
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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.
Blue Connect
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