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Plan forms
2023 Blue Medicare HMO Change Enrollment Form (PDF)
2022 Blue Medicare HMO Change Request Form (PDF)
2023 Blue Medicare PPO Change Enrollment Form (PDF)
2022 Blue Medicare PPO Change Request Form (PDF)
2023 Blue Medicare Rx (PDP) Change Application (PDF)
2022 Blue Medicare Rx (PDP) Change Request Form (PDF)
2023 EOC Blue Medicare HMO Choice 026 (PDF)
2023 EOC Blue Medicare HMO Essential 027 (PDF)
2023 EOC Blue Medicare PPO Enhanced 003 (PDF)
2023 EOC Blue Medicare PPO Freedom+ 004 (PDF)
2023 EOC Enhanced HMO-POS 024 (PDF)
2023 EOC PDP Enhanced 004 (PDF)
2023 EOC Blue Medical Only HMO-POS 012 (PDF)
2023 EOC Blue Medicare Essential Plus HMO-POS 023 (PDF)
2023 ANOC Blue Medicare Choice (HMO) (PDF)
2023 ANOC Blue Medicare Enhanced HMO 024-001 (PDF)
2023 ANOC Blue Medicare Enhanced HMO 024-002 (PDF)
2023 ANOC Blue Medicare Enhanced HMO 024-003 (PDF)
2023 ANOC Blue Medicare Medical Only HMO-POS (PDF)
2023 ANOC HMO Essential H3449-027-001 (PDF)
2023 ANOC HMO Essential H3449-027-002 (PDF)
2023 ANOC HMO Essential H3449-027-002 to 001 (PDF)
2023 ANOC HMO Essential Plus H3449-023-001 (PDF)
2023 ANOC HMO Essential Plus H3449-023-002 (PDF)
2023 ANOC HMO Essential Plus H3449-023-004 (PDF)
2023 ANOC HMO Essential Plus H3449-023-004 to 001 (PDF)
2023 ANOC HMO Essential Plus H3449-023-005 (PDF)
2023 ANOC PDP Enhanced S5540 004 (PDF)
2023 ANOC PDP Standard S5540-002 (PDF)
2023 ANOC PPO Enhanced 003-001 (PDF)
2023 ANOC PPO Enhanced 003-002 (PDF)
2023 ANOC Blue Medicare Enhanced HMO 024-003 to 001 (PDF)
Prescription drug forms
General forms
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.
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Disclosures:
Blue Cross and Blue Shield of North Carolina is an HMO, HMO-POS PPO and PDP plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal.
Blue Cross and Blue Shield of North Carolina Senior Health DBA Blue Cross and Blue Shield of North Carolina is an HMO-POS D-SNP plan with a Medicare contract and a NC State Medicaid Agency Contract (SMAC). Enrollment in Blue Cross and Blue Shield of North Carolina Senior Health depends upon contract renewal.
Blue Medicare Supplement plans offered: [Plan A: BMS A, 2/22, Plan G: BMS G, 2/22, Plan HI DED G: BMS HDG, 2/22, Plan K: BMS K, 2/22, Plan N: BMS N, 2/22.]
Blue Cross and Blue Shield of North Carolina does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, sexual orientation or source of payment. All Blue Cross and Blue Shield of North Carolina items and services are available to all eligible beneficiaries in the service area.
Links marked with an external site icon indicate that you're leaving BlueCrossNC.com and Blue Cross and Blue Shield of North Carolina's plan information. The site you're going to is either a third-party vendor contracted with Blue Cross NC to provide services or an external website independent of Blue Cross NC.
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The information on this page is current as of 10092022 | Y0079_11785_M CMS Accepted 10092022 | U36079, 092020
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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© 2023 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross NC is an abbreviation for Blue Cross and Blue Shield of North Carolina. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.