All Medicare Forms

For Blue Medicare HMO, Blue Medicare PPO and Blue Medicare Rx (PDP)

Download and print forms for managing your Medicare plans.

Blue Medicare HMO and Blue Medicare PPO Forms

Enrollment Forms

Mail-Order Prescription Drugs PDF Icon
If your Blue Medicare HMO or Blue Medicare PPO plan includes Medicare prescription drug coverage, download this form to enroll in our mail-order prescription drug program.


Authorization for Automatic Bank Draft Form PDF Icon
To register for bank draft payments of your premiums, download and complete the Authorization Agreement for Automatic Bank Draft Payments form. Include this form and a voided check for the bank account that will be drafted.


Enrollment Change Request Form
These forms should be used by current Blue Medicare HMO and PPO members to enroll in different Blue Medicare HMO and Blue Medicare PPO plans.

2018 Blue Medicare HMO Change Request Form PDF Icon

2018 Blue Medicare PPO Change Request Form PDF Icon

Personal Health Information Form

PHI Authorization Request Form PDF Icon
Use this form to give Blue Cross NC written permission to disclose your personal health information to anyone that you designate for any purpose.

Prescription Drug Request Forms

Prior authorization, step therapy, and exception requests require members to meet certain clinical criteria prior to a drug being covered. For prior authorization, step therapy, and exception requests, the member or the member's prescribing physician may contact Blue Medicare HMO, Blue Medicare PPO or Blue Medicare Rx. A physician's supporting statement is required for all requests before the prescription can be approved for payment. Physicians may contact the plan by calling Blue Medicare HMO or Blue Medicare PPO at 1-888-296-9790 or Blue Medicare Rx at 1-888-298-7552 or using the applicable fax request form (see below) to request an exception. After normal business hours messages can be left on the Part D After Hours Exception voice mail. Please see the member's formulary for detailed information regarding covered drugs and drugs requiring prior approval.

Criteria and forms are located on the prior authorization, tier exceptions, nonformulary exceptions, step therapy, and quantity limitations page.


Request for Medicare Prescription Drug Determination Form
Available for enrollees to download from the Centers for Medicare & Medicaid Services (CMS) website.

Claim Forms

Prescription Drug Claim Form PDF Icon
In most cases, there is no need to file a claim when filling your prescriptions. However, if you fill a formulary-covered prescription at an out-of-network pharmacy in case of an emergency, you should file a claim to receive coverage. Please include an itemized list of services and a paid receipt.


Vaccine Claim Form PDF Icon
If you received a Part D vaccine or had it administered at a location other than a participating pharmacy, you should file a claim to receive reimbursement for charges associated with the vaccine and its administration fee. Please include an itemized list of services and a paid receipt.

Blue Medicare Rx (PDP) Forms

Enrollment Forms

Mail-Order Prescription Drug Form PDF Icon
Download this form to enroll in our mail-order prescription drug program.


Authorization for Automatic Bank Draft Form PDF Icon
To register for bank draft payments of your premiums, download and complete the Authorization Agreement for Automatic Bank Draft Payments form. Include this form and a voided check for the bank account that will be drafted.


Enrollment Change Request Form 
This form should be used by current Blue Medicare Rx (PDP) members to enroll in a different Blue Medicare Rx (PDP) plan. 
2018 Blue Medicare Rx (PDP) Change Request Form PDF Icon

Personal Health and Coverage Information Forms

PHI Authorization Request Form PDF Icon
Use this form to give Blue Cross NC written permission to disclose your personal health information to anyone that you designate for any purpose.


Proof of Coverage
If your coverage with Blue Cross NC has ended and you need proof of coverage, please call the 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.

Prescription Drug Request Forms

Prior authorization, step therapy, and exception requests require members to meet certain clinical criteria prior to a drug being covered. For prior authorization, step therapy, and exception requests, the member or the member's prescribing physician may contact Blue Medicare HMO, Blue Medicare PPO or Blue Medicare Rx. A physician's supporting statement is required for all requests before the prescription can be approved for payment. Physicians may contact the plan by calling Blue Medicare HMO or Blue Medicare PPO at 1-888-296-9790 or Blue Medicare Rx at 1-888-298-7552 or using the applicable fax request form (see below) to request an exception. After normal business hours messages can be left on the Part D After Hours Exception voice mail. Please see the member's formulary for detailed information regarding covered drugs and drugs requiring prior approval.

Criteria and forms are located on the prior authorization, tier exceptions, nonformulary exceptions, step therapy, and quantity limitations page.


Request for Medicare Prescription Drug Determination Form
Available for enrollees to download from the Centers for Medicare & Medicaid Services (CMS) website.

Claim Forms

Prescription Drug Claim Form PDF Icon
In most cases, there is no need to file a claim when filling your prescriptions. However, if you fill a formulary-covered prescription at an out-of-network pharmacy in case of an emergency, you should file a claim to receive coverage. Please include an itemized list of services and a paid receipt.

Use the new, interactive form to complete your prescription drug claim form. You may enter your information directly on to the form, print it and mail it to us as usual. Tips for using the form:

  • When you click the new Print Form button on the claim, a message will be displayed if required information is missing.
  • Let your mouse hover over the text fields for helpful information.
  • If you save the form to your PC, only the blank form will be saved, not the text you entered.

Vaccine Claim Form PDF Icon
If you received a Part D vaccine or had it administered at a location other than a participating pharmacy, you should file a claim to receive reimbursement for charges associated with the vaccine and its administration fee. Please include an itemized list of services and a paid receipt.