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Plan Forms

  • 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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  • 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

    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 Choice EOC Spanish

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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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  • 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

    2021 Blue Medicare HMO Medical Only ANOC

    Download
  • PDF

    2021 Blue Medicare HMO Choice ANOC

    Download
  • PDF

    2021 Blue Medicare HMO Choice ANOC Spanish

    Download
  • 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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Prescription Drug Forms

  • PDF

    2021 VALUE Prior Authorization Criteria

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  • PDF

    2021 VALUE PLUS Prior Authorization Criteria

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  • PDF

    2021 IDEAL_IDEAL DSB Prior Authorization Criteria

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  • PDF

    2021 COMPLETE Prior Authorization Criteria

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  • PDF

    Blue Medicare Rx Standard

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  • PDF

    Blue Medicare Rx Enhanced

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  • PDF

    Blue Medicare PPO Employer Group Complete, Blue Medicare Rx Employer Group Complete, Blue Medicare HMO Employer Group Complete

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  • PDF

    Blue Medicare HMO Employer Group Ideal, Blue Medicare PPO Employer Group Ideal, Blue Medicare Rx Employer Group Ideal

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  • PDF

    Blue Medicare Choice, Blue Medicare Enhanced, Blue Medicare Essential, Blue Medicare Essential Plus, Blue Medicare PPO Enhanced

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  • PDF

    2021 Step Therapy Criteria: Value June

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  • PDF

    2021 Step Therapy Criteria: IDEAL

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  • PDF

    2021 Step Therapy Criteria: Value Plus September

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  • PDF

    2021 Step Therapy Criteria: Complete May

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  • PDF

    Blue Medicare Rx Standard

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  • PDF

    Blue Medicare PPO Employer Group Complete, Blue Medicare HMO Employer Group Complete, Blue Medicare Rx Employer Group Complete

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  • PDF

    Blue Medicare Rx Enhanced, Blue Medicare HMO Employer Group Ideal, Blue Medicare PPO Employer Group Ideal, Blue Medicare Rx Employer Group Ideal, Blue Medicare Choice, Blue Medicare Enhanced, Blue Medicare Essential, Blue Medicare Essential Plus, Blue Med

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  • PDF

    Medicare Part B vs Part D Fax Form

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  • PDF

    Medicare Part B Step Therapy Drug List September

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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