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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

    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

    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 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 August

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  • PDF

    2021 VALUE PLUS Prior Authorization Criteria August

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  • PDF

    2021 IDEAL_IDEAL DSB Prior Authorization Criteria August

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  • PDF

    2021 COMPLETE Prior Authorization Criteria August

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  • PDF

    2021 Step Therapy Criteria: Value June

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  • PDF

    2021 Step Therapy Criteria: IDEAL August

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  • PDF

    2021 Step Therapy Criteria: Value Plus August

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  • PDF

    2021 Step Therapy Criteria: Complete May

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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