Forms

Download and print out the forms you need to manage your health plan.

Claim forms

If you visit a network pharmacy to fill your prescription, and you have reached your deductible, you will pay only your copayment or coinsurance. If you visit an out-of-network pharmacy, you will have to file a claim for reimbursement and your out-of-pocket costs will be higher.

Prescription drugs

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.

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.

Member's 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. More