• 
• 
• 

Blue Medicare HMO and PPO forms

Mail Order Prescription Drugs
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.
Blue Medicare PPO Form
Blue Medicare HMO Form

Prescription Drug Claim Form
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 the case of an emergency, you should file a claim to receive coverage.

Vaccine Claim Form
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.

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

Authorization For Automatic Bank Drafts
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 with your enrollment materials. Your payments may also be deducted from your Social Security check. Please check the appropriate box on the enrollment form if you prefer this payment method. If you choose this payment method, you do not need to include a check for your first month's premium with your enrollment form.

   To view PDF documents you need Adobe Acrobat Reader.

Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1, 2011. Please contact Blue Medicare HMO, Blue Medicare PPO or Blue Medicare Rx (PDP) for details.

Blue Cross Blue Shield of North Carolina (BCBSNC) is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. BCBSNC does not discriminate based on color, gender, religion, national origin, age, race, disability, handicap, sexual orientation, genetic information, source of payment or health status as defined by the Centers for Medicare & Medicaid Services (CMS). All qualified Medicare beneficiaries may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or another third party. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association.

The information on this page is current as of 10/01/2009.