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.
Use this form to give BCBSNC written permission to disclose your personal health information to anyone that you designate for any purpose.
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.
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.
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 of each year. Please contact BCBSNC 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 is a Medicare-approved Part D sponsor. BCBSNC 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 or geographic location within the service area. All BCBSNC items and services are available to all eligible beneficiaries in the service area.
Limitations, copayments, and restrictions 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 you would like Medicare Advantage or Part D documents in a different language or format, or your coverage has ended and you need proof of coverage or a Certification of Health Insurance Coverage, you can call us 7 days a week, 8a.m. to 8 p.m.
The information on this page is current as of 10/01/2012.
Y0079_5875 CMS Approved 10012012