Skip Navigation

Important Legal Information and Disclaimers

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

Forms

  • Text Size
  • Decrease Text Size
  • Increase Text Size
Blue Medicare HMO and PPO Forms

Enrollment 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.

Authorization for Automatic Bank Draft Form
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.

2015 Blue Medicare HMO Change Request Form
2015 Blue Medicare PPO Change Request Form

Multi-Language Intepreter Services (pdf)

Personal Health Information Form

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.

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 and 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
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. Please include the itemized list of services and a paid receipt.

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. Please include the itemized list of services and a paid receipt.



Get Acrobat   To view PDF documents you need Adobe Acrobat Reader.

Important Legal Information and Disclaimers

The information on this page is current as of 10/1/2014.

Y0079_6741 CMS Approved 10022014