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Blue Medicare Rx forms

Mail Order Prescription Drugs
Download this form to enroll in our mail-order prescription drug program.

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.

Use this 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.
• Hover your mouse 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
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.

Member Authorization Request Form
The Health Insurance Portability and Accountability Act (HIPAA) is federal regulation that protects your privacy by governing the way health care companies and medical care providers are permitted to use and disclose information about you. If you usually rely on your spouse, family member or close friend to contact us for claims or payment information, we can no longer release information to them unless we have a signed authorization from you.

EasyPayBlue^SM Enrollment Form
There's an easy and convenient way to pay your monthly premiums. As a Blue Medicare Rx member, you can have your monthly premiums automatically deducted from your bank account through our EasyBluePay program. You won't have to worry about writing a check, paying for postage or mailing your premium payment ever again. Just submit the enrollment form to begin.

Proof of coverage portability certificate
If your coverage with BCBSNC has ended and you need a proof of coverage portability certificate to verify the length of your coverage, you can order it here. 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 BCBSNC Blue Medicare Rx ID card.

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®, SM Mark of the Blue Cross and Blue Shield Association. SM1 Mark of Blue Cross and Blue Shield of North Carolina.

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