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Plan 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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  • 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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  • 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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Prescription Drug Forms

  • 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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  • 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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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