Knowledge Center

Reimbursement varies according to plans. For more information, please refer to your Member Guide to find out if benefits are available for pharmacies outside of your network.

If you will be going out of town for an extended time, benefits are available for an extended supply of up to 90 days for prescription drugs. However, you cannot refill a prescription until three-fourths of your current supply has been used. If you have not used three-fourths of your current supply but do not have enough medication to last through your trip, speak with your pharmacist about an early refill for up to an additional 30-day supply. If this amount is not enough, call Blue Cross NC Customer Service at 877-258-3334 for assistance. 

Note: In some cases, employer groups carve out the prescription drug benefit and contract with a vendor separately, please refer to your Member Guide to confirm that your pharmacy benefits are offered through Blue Cross NC.

The Blue Cross NC prescription drug formulary is a list of FDA-approved prescription drugs reviewed and maintained by the Blue Cross NC Pharmacy and Therapeutics (P&T) Committee, comprised of independent physicians and pharmacists. Blue Cross NC offers an open formulary; therefore, no drugs are considered non-formulary.

If your prescription drug benefit is based on copayments, the formulary can help you determine your copayment for a specific drug. It also provides a list of possible therapeutic alternatives that may be available at a lower copayment.

If your prescription drug benefit is based on coinsurance, the formulary can help you identify any available low-cost, generic drugs.

Formulary information is available in the Find Care search tool in Blue Connect℠. If you would like a full copy of the formulary, free of charge, please call Blue Cross NC's Customer Service at 877-258-3334. You should bring your copy of the formulary with you when you visit the doctor. 

Note: In some cases, employer groups carve out the prescription drug benefit and contract with a vendor separately. Please refer to your Member Guide to confirm that your pharmacy benefits are offered through Blue Cross NC.

Sometimes you go to the doctor for preventive care and end up with a charge on your bill. You can avoid surprising costs by following these steps:

• When you schedule an appointment, ask for preventive care screenings and tests that are 100% covered by your plan.
• Ask if any tests or treatments done during your appointment are not considered preventive care.
• Ask if talking about other health problems that are not considered preventive care during your appointment will lead to extra costs.
• Ask if lab work can be sent to a Blue Cross NC in-network lab.

Access the most up-to-date provider information with our Find Care search tool in Blue Connect℠. With it, you can locate providers by name, specialty, county or ZIP Code. The Provider Search information is updated weekly.

You can also contact Customer Service at 877-258-3334 for help locating a provider. Also, many employers have a directory in their Human Resources department.

Blue Cross NC will mail a comprehensive Benefit Booklet to your home after you enroll. Your Benefit Booklet is also available on the Coverage page in your Blue Connect℠ member portal. It has detailed information about your specific benefits and covered services.

You'll find a lot of information on benefits, claims and other member services on our website and in your Blue Connect member portal.
Log in to Blue Connect to see your:

• Member ID cards
• Plan benefits
• Claim status
• Bill pay options
• Deductible balances, copayment amounts, coinsurance percentages, and other out-of-pocket costs
• Contact information in the Contact Preferences Center

Need help?
You can send a secure message anytime through Blue Connect or call 877-258-3334, Monday to Friday, 8 AM to 7 PM ET.

You have the right to request a formal appeal of the claim payment or denial. Log in to Blue Connect℠ to check your Benefit Booklet or call the Customer Service number on the back of your member ID card for a detailed description of this process.

Blue Cross NC will work with you to resolve the issue. For each step in the appeals process, there are specified time frames for filing a grievance and for Blue Cross NC to notify you or your provider of the decision.

Prior approval and referrals depend on your plan. Visit the Coverage page of your Blue Connect℠ member portal to find the rules listed in your Benefit Booklet.

If you need to submit a claim, please mail it in time to be received by Blue Cross NC within 18 months after the service was provided. Claims not received within 18 months from the date the service was provided will not be covered, except in the absence of legal capacity of the member.

Answers vary according to your plan. To learn more, log in to Blue Connect to see the coverage details in your Benefit Booklet or call the Customer Service number on the back of your member ID card.

If you have an individual or family health insurance plan: You can cover a newborn from their date of birth if the parent already has a health insurance plan in effect at the time of birth. The parent has 60 days to contact Customer Service to add the newborn to their existing plan.

 If you have a health insurance plan through your employer: You must notify your employer or group administrator to add a newborn to your coverage. Some employer groups opt for a 60-day notice.

Please check your Benefit Booklet to find out how much notice is required by your plan.

Everyone under the age of 65 has the opportunity to purchase health insurance during the Open Enrollment Period.

Open Enrollment is from November 1 to December 15 every year for coverage starting on January 1.

You can purchase or change a plan outside of Open Enrollment if you have a qualifying life event. There are many things that can be considered a qualifying life event, like: loss of health coverage (losing a job, turning 26, or graduating and losing a student plan), turning 65 and needing to purchase a Medicare plan, changes to your household (having a baby, getting married or divorced, death in the family), changes to your physical location (moving to a new county or ZIP Code, moving from a shelter into a home), becoming a US citizen, leaving jail or prison, and/or changes to your income that may affect a subsidy you qualify for.