Draft Forms

 

2021 BlueCross BlueShield Medicare Advantage/Rx PHI Disclosure Form (PDF)    

2021 BlueCross Rx Plus (PDP) EOC

2021 BlueCross Rx Value (PDP) EOC

2021 BlueCross Rx Value and Rx Plus Enrollment Application (PDF)

2021 BlueCross Secure Greenville EOC

2021 BlueCross Secure HMO MAPD Enrollment Application (PDF)

2021 BlueCross Secure HMO Provider Directory (PDF) 

2021 BlueCross Secure HMO Star Ratings

2021 BlueCross Secure Richland EOC    

2021 BlueCross Secure Summary of Benefits (PDF)

2021 BlueCross Total PPO Enrollment Application (PDF)

2021 BlueCross Total PPO Star Ratings

2021 BlueCross Total Summary of Benefits (PDF)

2021 BlueCross Total Value PPO Enrollment Application (PDF)

2021 BlueCross Total Value PPO Step Therapy Criteria (PDF)

2021 BlueCross Total Value Prior Authorization Criteria (PDF)

2021 BlueCross Total Value Summary of Benefits (PDF)

2021 BlueCross Total/Total Value Provider Directory (PDF)    

2021 BlueCross Total/Total Value Provider Directory (URL)

2021 MA Transition Policy (PDF)

2021 MAPD PA Criteria

2021 MAPD Pharmacy Directory

2021 MAPD ST Criteria

2021 Medicare Extra Help Program

2021 Medicare Therapy Management Program

2021 PDP PA Criteria

2021 PDP Pharmacy Directory    

2021 PDP ST Criteria 

2021 PDP Star Ratings

2021 Prescription Drug Mail Order Form (PDF)

2021 Rx Coverage Determination Form (PDF)

2021 Rx Coverage Redetermination Form (PDF)

2021 Rx Medicare Extra Help Program

2021 Rx Plus 2021 Formulary

2021 Rx Prescription Drug Transition Policy (PDF)

2021 Rx Value and Rx Plus Summary of Benefits(PDF)

2021 Rx Value/Rx Plus Coverage Determinations and Redeterminations (PDF)

2021 Rx Value/Rx Plus LIS Summary

2021 Rx Value/Rx Plus Pharmacy Directory (PDF)

2021 Total Lowcountry EOC

2021 Total Midlands-Coastal EOC

2021 Total Upstate EOC

2021 Total Value Comprehensive Formulary

2021 Total Value Midlands-Coastal EOC

2021 Total Value Upstate EOC

2021 Total/Secure Comprehensive Formulary

Appointment of Representative Form (PDF)

BlueCross Rx Value and Rx Plus Plan Rating (PDF)

BlueCross Secure LIS Summary

BlueCross Total LIS Summary

BlueCross Total Value LIS Summary

MAPD Out of Network Coverage Rules

Medicare Advantage (Medical) claim form

Medicare Advantage Grievance Information

OON Drug Coverage Rules

Prescription drug claim form (PDF)

Prescription Drug Grievance Information    

Rx Value 2021 Formulary

 

Multi-Language and Non-Discrimination Policy
LIS Premium Summary Chart
Beneficiary Rights and Responsibilities Upon Disenrollment
Our Privacy Practices

Coverage decisions are decisions we make about whether a service is covered by the plan and the amount, if any, we are required to pay for the service. Coverage decisions are also call organization determinations. If you are not satisfied with the outcome of a coverage decision, you can appeal the decision by requesting a plan reconsideration. Learn more about coverage decisions and reconsiderations, and filing grievances. Call a customer service representative to get an aggregate number of grievances and appeals filed with BlueCross Secure.

To request a coverage decision or reconsideration:

Call 1-855-204-2744 (TTY 711)
Fax your request to 1-803-264-9581
Email your request to medhelp@bcbssc.com
Download a reconsideration request form
You can name another person to act as your “representative” and ask for a coverage decision or reconsideration on your behalf, such as a friend, relative, doctor or other prescriber. To have a representative act on your behalf, both you and the representative must sign the Appointment of Representative Form.

 

BlueCross BlueShield of South Carolina is a Medicare Advantage PPO and HMO plan with a Medicare contract. BlueCross Essential, Rx Value and BlueCross Rx Plus are stand-alone prescription drug plans with a Medicare contract. Enrollment in BlueCross Total, BlueCross Total Value, BlueCross Blue Basic, BlueCross Secure, BlueCross Essential, BlueCross Rx Value or BlueCross Rx Plus depends on contract renewal.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year.

Out-of-network/non-contracted providers are under no obligation to treat BlueCross BlueShield of South Carolina Medicare members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call Customer Service or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

BlueCross BlueShield of South Carolina does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in our health plans, when we enroll members or provide benefits. Free language interpretation services are available for those who cannot read or speak English. Read our Non-Discrimination Statement and Foreign Language Access policy.