Forms Library

Our complete forms library for Blue Medicare Advantage, Blue Medicare Supplement and Blue Medicare Rx (PDP) plans.

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Plan Forms

Enrollment Change Forms

• PDF

  2020 Blue Medicare HMO Change Request Form

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• PDF

  2020 Blue Medicare PPO Change Request Form

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• PDF

  2020 Blue Medicare Rx (PDP) Change Request Form

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• PDF

  2021 Blue Medicare HMO Change Request Form

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• PDF

  2021 Blue Medicare Rx (PDP) Change Request Form

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Claim Forms

• PDF

  Medical and Dental Claim Form

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• PDF

  Prescription Drug Claim Form

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• PDF

  Vaccine Claim Form

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Evidence of Coverage

• PDF

  2020 Blue Medicare HMO Medical Only

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• PDF

  2020 Blue Medicare HMO Choice

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• PDF

  2020 Blue Medicare HMO Enhanced 024 001 002 and 003

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• PDF

  2020 Blue Medicare HMO Essential 025

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• PDF

  2020 Blue Medicare HMO Essential Plus 023 001 and 002

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• PDF

  2020 Blue Medicare HMO Essential Plus 023 004 and 005

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• PDF

  2020 Blue Medicare PPO Enhanced 003 001 and 002

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• PDF

  2020 Blue Medicare Rx (PDP) Standard 002

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• PDF

  2020 Blue Medicare Rx (PDP) Enhanced 004

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• PDF

  2021 Blue Medicare HMO Medical Only EOC

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• PDF

  2021 Blue Medicare HMO Choice EOC

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• PDF

  2021 Blue Medicare HMO Enhanced EOC

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• PDF

  2021 Blue Medicare HMO Essential EOC

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• PDF

  2021 Blue Medicare HMO Essential Plus 023-001 and 002 EOC

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• PDF

  2021 Blue Medicare HMO Essential Plus 023-004 and 005 EOC

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• PDF

  2021 Blue Medicare PPO Enhanced EOC

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• PDF

  2021 Blue Medicare Rx (PDP) Standard EOC

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• PDF

  2021 Blue Medicare Rx (PDP) Enhanced EOC

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• PDF

  2021 Healthy Blue + Medicare (HMO D-SNP)

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Annual Notice of Changes

• PDF

  2020 Blue Medicare HMO Medical Only

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• PDF

  2020 Blue Medicare HMO Essential Plus 023 001 to 023 001

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• PDF

  2020 Blue Medicare HMO Essential Plus 023 001 to 023 002

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• PDF

  2020 Blue Medicare HMO Essential Plus 023 002 to 023 001

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• PDF

  2020 Blue Medicare HMO Essential Plus 023 002 to 023 002

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• PDF

  2020 Blue Medicare HMO Essential Plus 023 002 to 023 004

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• PDF

  2020 Blue Medicare HMO Essential Plus 023 004 to 023 002

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• PDF

  2020 Blue Medicare HMO Essential Plus 023 004 to 023 005

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• PDF

  2020 Blue Medicare HMO Enhanced 024 001 to 024 001

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• PDF

  2020 Blue Medicare HMO Enhanced 024 001 to 024 002

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• PDF

  2020 Blue Medicare HMO Enhanced 024 002 to 024 001

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• PDF

  2020 Blue Medicare HMO Enhanced 024 002 to 024 002

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• PDF

  2020 Blue Medicare HMO Enhanced 024 002 to 024 003

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• PDF

  2020 Blue Medicare PPO Enhanced 003 001 to 001

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• PDF

  2020 Blue Medicare PPO Enhanced 003 001 to 002

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• PDF

  2020 Blue Medicare PPO Enhanced 003 002 to 001

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• PDF

  2020 Blue Medicare PPO Enhanced 003 002 to 002

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• PDF

  2021 Blue Medicare HMO Medical Only ANOC

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• PDF

  2021 Blue Medicare HMO Choice ANOC

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• PDF

  2021 Blue Medicare HMO Essential ANOC

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• PDF

  2021 Blue Medicare HMO Essential Plus 023-001 ANOC

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• PDF

  2021 Blue Medicare HMO Essential Plus 023-002 ANOC

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• PDF

  2021 Blue Medicare HMO Essential Plus 023-004 ANOC

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• PDF

  2021 Blue Medicare HMO Essential Plus 023-005 ANOC

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• PDF

  2021 Blue Medicare HMO Enhanced 024-001 ANOC

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• PDF

  2021 Blue Medicare HMO Enhanced 024-002 ANOC

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• PDF

  2021 Blue Medicare HMO Enhanced 024-003 ANOC

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• PDF

  2021 Blue Medicare PPO Enhanced 003-001 ANOC

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• PDF

  2021 Blue Medicare PPO Enhanced 003-002 ANOC

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• PDF

  2021 Blue Medicare Rx (PDP) Standard ANOC

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• PDF

  2021 Blue Medicare Rx (PDP) Enhanced ANOC

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Limitations and Exclusions

2020

 

Blue Medicare Rx (PDP) 

 

Blue Medicare Advantage 

Star Ratings

• PDF

  2020 Blue Medicare HMO Star Ratings

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• PDF

  2020 Blue Medicare PPO Star Ratings

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• PDF

  2020 Blue Medicare Rx Star Ratings

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• PDF

  2020 Basic Blue Rx Star Ratings

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• PDF

  2021 Blue Medicare HMO Star Ratings

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• PDF

  2021 Blue Medicare PPO Star Ratings

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• PDF

  2021 Blue Medicare Rx Star Ratings

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Prescription Drug Forms

Prior Authorization Criteria

• PDF

  2020 Prior Authorization Criteria: Value

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• PDF

  2020 Prior Authorization Criteria: Value Plus

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• PDF

  2020 Prior Authorization Criteria: IDEAL DSB

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• PDF

  2021 Prior Authorization Criteria: Value

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• PDF

  2021 Prior Authorization: Value Plus

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• PDF

  2021 Prior Authorization: IDEAL DSB

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• PDF

  2021 Prior Authorization: Complete

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Step Therapy Criteria

• PDF

  2020 Step Therapy Criteria: Value

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• PDF

  2020 Step Therapy Criteria: IDEAL

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• PDF

  2021 Step Therapy Criteria: Value

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• PDF

  2021 Step Therapy Criteria: IDEAL

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• PDF

  2021 Step Therapy Criteria: Value Plus

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• PDF

  2021 Step Therapy Criteria: Complete

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Quantity Limits

• PDF

  Quantity Limit Exception Criteria

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• PDF

  Quantity Limit Fax Form

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Medicare Part B vs Part D

• PDF

  Medicare Part B vs Part D Fax Form

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• PDF

  Medicare Part B Step Therapy Drug List

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Non-Formulary Exceptions

• PDF

  Non-Formulary Exception Criteria

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• PDF

  Non-Formulary Exception Fax Form

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Tier Exceptions

• PDF

  Tier Exception Criteria

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• PDF

  Tier Exception Fax Form

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General Prescription Drug Forms

• PDF

  Compounded Drugs Fax Form

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• PDF

  Coverage Determination Form

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• PDF

  Excluded Drugs List

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• PDF

  Hospice Fax Form

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• PDF

  Mail Order Rx Form

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• PDF

  Request for Medicare Prescription Drug Determination Form

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General Forms

General Forms

• PDF

  Authorization for Automatic Bank Draft Form

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• PDF

  Appointment of Representative (AOR) Form

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• PDF

  PHI Authorization Request Form

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• PDF

  Diabetes Prevention Program

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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.

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