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

  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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2022 Evidence of Coverage

• 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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2021 Evidence of Coverage

• 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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2022 Annual Notice of Changes

• 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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2021 Annual Notice of Changes

• 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

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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

 

Blue Medicare Rx (PDP) 

 

Blue Medicare Advantage 

Star Ratings

• PDF

  2022 Blue Medicare HMO Star Ratings

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• PDF

  2022 Blue Medicare PPO Star Ratings

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• PDF

  2022 Blue Medicare 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

2021 Prior Authorization Criteria

• 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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2022 Prior Authorization Criteria

• 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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2021 Step Therapy Criteria

• 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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2022 Step Therapy Criteria

• 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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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 September

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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

  Request Form - Tier Exception Fax

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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

  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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