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Blue Medicare Rx Forms

Enrollment Forms

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

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 EasyPayBlue 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.

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.
2013 Blue Medicare Rx (PDP) Change Request Form

Personal Health and Coverage Information Forms

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.

Proof of Coverage
If your coverage with BCBSNC has ended and you need proof of coverage, please call the Customer Service number on the back of your BCBSNC 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 BCBSNC 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 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.

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.
• 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
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.

®, 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 10/01/2012.

Y0079_5875 CMS Approved 10012012