Member Booklets, Forms & Documents

To help you manage your benefits from Blue Cross NC



For Individuals and Families Under Age 65

Blue Cross NC members can file a claim, appeal a denial of benefits, and learn more about their coverage depending on their type of plan. Look for Medicare, Dental and Vision documents below.

Don't see what you need? Log in to Blue Connect or call the customer service number on the back or your member ID card. 

Claims Forms

Claims for Benefits Received in North Carolina or Out-of-Network in the U.S.

Note: most providers in the Blue Cross NC network will file a claim on your behalf.


Claims for services received outside NC:


Claims for benefits received outside the U.S.

For benefits received on a cruise ship while outside the country; please submit the domestic claim forms.

    Appeals Forms

    These appeals forms are unintended for appealing underwriting decisions. If you wish to appeal an underwriting decision, try one of the following:

    • Check your underwriting decision letter for appeal instructions.
    • Contact your local agent.
    • Call us at 1-888-922-3140.

    Benefits Documents

    Additional Information

    Members log in to Blue Connect for more information:


    About Interactive PDFs: You can add your information directly on the form to complete it, however, completed forms cannot be saved. You can save a blank version of the form. We recommend printing a copy for Blue Cross NC and one for your records. To view PDF documents you need Adobe Acrobat Reader, provided free from Adobe.com.



    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.

    2019 Blue Medicare HMO Change Request Form PDF Icon

    2019 Blue Medicare PPO Change Request Form PDF Icon


    Diabetes Prevention Program PDF Icon

    Download this Patient Referral Form to share with your PCP then have them send your current lab results to Solera Health to enroll you in the program.

    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. 
    2019 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.