Forms & Policies 2024
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BlueCross Medicare Advantage Plan Documents and Forms
Secure HMO Plan
- 2024 BlueCross SecureSM Summary of Benefits (PDF)
- 2024 BlueCross Secure Greenville Annual Notice of Changes (PDF)
- 2024 BlueCross Secure Richland Annual Notice of Changes (PDF)
- 2024 BlueCross Secure Greenville HMO Evidence of Coverage (PDF)
- 2024 BlueCross Secure Richland HMO Evidence of Coverage (PDF)
- 2024 BlueCross Secure HMO Provider Directory (PDF) (Updated 10/01/2024)
- Vision Care Providers
- 2024 BlueCross Secure HMO Provider Look-Up Tool (URL)
- 2024 BlueCross Secure/TotalSM/Total ValueSM Pharmacy Directory (PDF) (Updated 10/08/2024)
- 2024 Secure/Total Comprehensive Formulary (PDF) (Updated 09/03/2024, Effective 10/01/2024)
- 2024 Secure/Total Prior Authorization Criteria (PDF)
- 2024 Secure/Total Step Therapy Criteria (PDF)
- 2024 BlueCross Secure/Total Drug Look-Up Tool (URL)
- 2024 BlueCross HMO Star Ratings (PDF)
- 2024 BlueCross Secure LIS Summary (PDF)
- 2024 BlueCross Secure HMO MAPD Enrollment Application (PDF)
Total PPO Plan
- 2024 BlueCross Total Summary of Benefits (PDF)
- 2024 BlueCross Total Lowcountry ANOC (PDF)
- 2024 BlueCross Total Midlands Coastal ANOC (PDF)
- 2024 BlueCross Total Upstate ANOC (PDF)
- 2024 BlueCross Total Lowcountry PPO Evidence of Coverage (PDF)
- 2024 BlueCross Total Midlands/Coastal PPO Evidence of Coverage (PDF)
- 2024 BlueCross Total Upstate PPO Evidence of Coverage (PDF)
- 2024 BlueCross Total/Total Value/Blue Basic Provider Directory (PDF) (Updated 10/01/2024)
- 2024 BlueCross Total/Total Value/Blue Basic Provider Look-Up Tool (URL)
- Vision Care Providers
- 2024 BlueCross Total/Total Value/Blue Basic Out-of-State Provider Lookup (URL)
- 2024 Secure/Total/Total Value Pharmacy Directory (PDF) (Updated 10/08/2024)
- 2024 Secure/Total Comprehensive Formulary (PDF) (Updated 09/03/2024, Effective 10/01/2024)
- 2024 Secure/Total Prior Authorization Criteria (PDF)
- 2024 Secure/Total Step Therapy Criteria (PDF)
- 2024 BlueCross Secure/Total Drug Look-Up Tool (URL)
- 2024 BlueCross PPO Star Ratings (PDF)
- 2024 Total PPO LIS Summary (PDF)
- 2024 BlueCross Total Enrollment Application (PDF)
- Out of Network Coverage Rules (PDF)
Total Value PPO Plan
- 2024 BlueCross Total Value Summary of Benefits (PDF)
- 2024 BlueCross Total Value Lowcountry ANOC (PDF)
- 2024 BlueCross Total Value Midlands Coastal ANOC (PDF)
- 2024 BlueCross Total Value Upstate ANOC (PDF)
- 2024 Total Value Lowcountry PPO Evidence of Coverage (PDF)
- 2024 Total Value Midlands/Coastal PPO Evidence of Coverage (PDF)
- 2024 Total Value Upstate PPO Evidence of Coverage (PDF)
- 2024 BlueCross Total/Total Value/Blue Basic Provider Directory (PDF) (Updated 10/01/2024)
- 2024 BlueCross Total/Total Value/Blue Basic Provider Look-Up Tool (URL)
- 2024 BlueCross Total/Total Value/Blue Basic Out-of-State Provider Lookup (URL)
- Vision Care Providers
- 2024 Secure/Total/Total Value Pharmacy Directory (PDF) (Updated 10/08/2024)
- 2024 Total Value Formulary (PDF) (Updated 09/03/2024, Effective 10/01/2024)
- 2024 Total Value Prior Authorization Criteria (PDF)
- 2024 Total Value Step Therapy Criteria (PDF)
- 2024 BlueCross Total Value Drug Look-Up Tool (URL)
- 2024 BlueCross PPO Star Ratings (PDF)
- 2024 Total Value PPO LIS Summary (PDF)
- 2024 BlueCross Total Value PPO Enrollment Application (PDF)
- Out of Network Coverage Rules (PDF)
Blue Basic PPO Plan
- 2024 BlueCross Blue BasicSM Summary of Benefits (PDF)
- 2024 BlueCross Blue Basic ANOC (PDF)
- 2024 BlueCross Blue Basic EOC (PDF)
- 2024 BlueCross Total/Total Value/Blue Basic Provider Directory (PDF) (Updated 10/01/2024)
- 2024 BlueCross Total/Total Value/Blue Basic Provider Look-Up (URL)
- 2024 BlueCross Total/Total Value/Blue Basic Out-of-State Provider Lookup (URL)
- Vision Care Providers
- 2024 BlueCross PPO Star Ratings (PDF)
- 2024 BlueCross Blue Basic Enrollment Application (PDF)
- Out of Network Coverage Rules (PDF)
BlueCross Rx Plans
BlueCross Rx Essential
- 2024 Rx EssentialSM Summary of Benefits (PDF)
- 2024 Rx Essential ANOC (PDF)
- 2024 Rx Essential EOC (PDF)
- 2024 Rx Essential/Rx Value/Rx Plus Pharmacy Directory (PDF) (Updated 10/08/2024)
- 2024 Rx Essential Comprehensive Formulary (PDF) (Updated 09/03/2024, Effective 10/01/2024)
- 2024 Rx Essential Prior Authorization Criteria (PDF)
- 2024 Rx Essential Step Therapy Criteria (PDF)
- 2024 Rx Essential Drug Look-Up Tool (URL)
- 2024 BlueCross PDP Star Ratings (PDF)
- 2024 Rx Essential/Rx Value/Rx Plus LIS Summary (PDF)
- 2024 Rx Essential, Rx Value and Rx Plus Enrollment Application (PDF)
BlueCross Rx Value
- 2024 Rx ValueSM Summary of Benefits (PDF)
- 2024 BlueCross Rx Value Annual Notice of Change (PDF)
- 2024 BlueCross Rx Value EOC (PDF)
- 2024 Rx Essential/Rx Value/Rx Plus Pharmacy Directory (PDF) (Updated 10/08/2024)
- 2024 Rx Value Comprehensive Formulary (PDF) (Updated 09/03/2024, Effective 10/01/2024)
- 2024 Rx Value Prior Authorization Criteria (PDF)
- 2024 Rx Value Step Therapy Criteria (PDF)
- 2024 BlueCross Rx Value Drug Look-Up Tool (URL)
- 2024 BlueCross PDP Star Ratings (PDF)
- 2024 Rx Essential/Rx Value/Rx Plus LIS Summary (PDF)
- 2024 BlueCross Rx Essential, Rx Value and Rx Plus Enrollment Application (PDF)
BlueCross Rx Plus
- 2024 Rx PlusSM Summary of Benefits (PDF)
- 2024 BlueCross Rx Plus Annual Notice of Change (PDF)
- 2024 BlueCross Rx Plus EOC (PDF)
- 2024 Rx Essential/Rx Value/Rx Plus Pharmacy Directory (PDF) (Updated 10/08/2024)
- 2024 Rx Plus Comprehensive Formulary (PDF) (Updated 09/03/2024, Effective 10/01/2024)
- 2024 Rx Plus Prior Authorization Criteria (PDF)
- 2024 Rx Plus Step Therapy Criteria (PDF)
- 2024 BlueCross Rx Plus Drug Look-Up Tool (URL)
- 2024 BlueCross PDP Star Ratings (PDF)
- 2024 Rx Essential/Rx Value/Rx Plus LIS Summary (PDF)
- 2024 BlueCross Rx Essential, Rx Value and Rx Plus Enrollment Application (PDF)
Blue Retiree Rx Plans
Blue Retiree Rx Essential
- 2024 Blue RetireeSM Rx Essential Summary of Benefits (PDF)
- 2024 Blue Retiree Rx Essential Annual Notice of Changes (PDF)
- 2024 Blue Retiree Rx Essential EOC (PDF)
- 2024 Blue Retiree Rx Essential/Rx/Rx Plus Pharmacy Directory (PDF) (Updated 10/08/2024)
- 2024 Blue Retiree Rx Essential Comprehensive Formulary (PDF) (Updated 09/03/2024, Effective 10/01/2024)
- 2024 Blue Retiree Rx Essential Prior Authorization Criteria (PDF)
- 2024 Blue Retiree Rx Essential Step Therapy Criteria (PDF)
- 2024 Blue Retiree Rx Essential Drug Look-Up Tool (URL)
- 2024 Blue Retiree PDP Star Ratings (PDF)
- 2024 Blue Retiree Rx LIS Summary (PDF)
- 2024 Blue Retiree Rx Essential, Rx and Rx Plus Enrollment Application (PDF)
Blue Retiree Rx
- 2024 Blue Retiree Rx Summary of Benefits (PDF)
- 2024 Blue Retiree Rx Annual Notice of Changes (PDF)
- 2024 Blue Retiree Rx EOC (PDF)
- 2024 Blue Retiree Rx Essential/Rx/Rx Plus Pharmacy Directory (PDF) (Updated 10/08/2024)
- 2024 Blue Retiree Rx Comprehensive Formulary (PDF) (Updated 09/03/2024, Effective 10/01/2024)
- 2024 Blue Retiree Rx Prior Authorization Criteria (PDF)
- 2024 Blue Retiree Rx Step Therapy Criteria (PDF)
- 2024 Blue Retiree Rx/Rx Plus Drug Look-Up Tool (URL)
- 2024 Blue Retiree PDP Star Ratings (PDF)
- 2024 Blue Retire Rx LIS Summary (PDF)
- 2024 Blue Retiree Rx Essential, Rx and Rx Plus Enrollment Application (PDF)
Blue Retiree Rx Plus
- 2024 Blue Retiree Rx Plus Summary of Benefits (PDF)
- 2024 Blue Retiree Rx Plus Annual Notice of Changes (PDF)
- 2024 Blue Retiree Rx Plus EOC (PDF)
- 2024 Blue Retiree Rx Essential/Rx/Rx Plus Pharmacy Directory (PDF) (Updated 10/08/2024)
- 2024 Blue Retiree Rx Plus Comprehensive Formulary (PDF) (Updated 09/03/2024, Effective 10/01/2024)
- 2024 Blue Retiree Rx Plus Prior Authorization Criteria (PDF)
- 2024 Blue Retiree Rx Plus Step Therapy Criteria (PDF)
- 2024 Blue Retiree Rx/Rx Plus Drug Look-Up Tool (URL)
- 2024 Blue Retiree PDP Star Ratings (PDF)
- 2024 Blue Retiree Rx LIS Summary (PDF)
- 2024 Blue Retiree Rx Essential, Rx and Rx Plus Enrollment Application (PDF)
General Forms and Policies
- OTC Products and Food List (PDF)
- Authorization Agreement for Pre-Arranged Payments (PDF)
- BlueCross MAPD Preferred Test Strips Vendor Notice (PDF)
- BlueCross BlueShield Medicare Advantage/Rx PHI Disclosure Form (PDF)
- MA Transition Policy (PDF)
- Rx Prescription Drug Transition Policy (PDF)
- Medicare Extra Help Program (PDF)
- Medicare Therapy Management Program (PDF)
- Pharmacy Locator (URL)
- Prescription Drug Mail Order Form (PDF)
- Privacy Practices Notice (PDF)
- Rights and Responsibilities Upon Disenrollment (PDF)
- Appointment of Representative Form Rev 8-18 (PDF)
- Multi-Language Interpreter Services – Medicare Advantage (PDP)
- Multi-Language Interpreter Services – Prescription Drug Plans (PDP)
- CMS Best Available Evidence (BAE) (URL)
- MA Coverage Decision and Appeal Information (PDF)
- Medicare Advantage (Medical/Dental) claim form (PDF)
- Medicare Advantage Grievance Information (PDF)
- Medicare Advantage Reconsideration Request Form (PDF)
- Medicare Ombudsman (URL)
- Prescription Drug Claim Form (PDF)
- Rx Coverage Determination Form (PDF)
- Prescription Drug Grievance Information (PDF)
- Rx Out of Network Coverage Rules (PDF)
- Rx Coverage Redetermination Form (PDF)
- Rx Coverage Determinations and Redeterminations Policy (PDF)
- 2024 PPO Comparison Chart (PDF)
Coverage Decisions, Appeals and Complaints
- Coverage decision: 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 called organization determinations.
- Appeal: if you are not satisfied with the outcome of a coverage decision, you can appeal the decision by requesting a plan reconsideration.
- Grievance: any complaint other than one that involves an Organization Determination.
- Coverage Determinations and Appeals — Medicare Advantage
Coverage Determination Details
When you ask for a decision about a Medicare Advantage health benefit or the amount we will pay for a service, you are requesting a coverage decision, which is also called an organization determination. If your health care provider tells you that we will not cover a service, or if you are charged more than you think your copayment or coinsurance should be, you or your provider may ask us for an organization determination.
The following are examples of when you can ask us for an organization determination:
- You are requesting payment for a service furnished by a provider that you believe should have been reimbursed by the health plan
- You are requesting payment for out-of-the-area renal dialysis services
- You have been told we are reducing or discontinuing a previously authorized service
- You are requesting payment for emergency services
When you request an organization determination, you will receive a response from us within:
- 72 hours for a pre-service expedited decision
- 14 days for a standard decision
- 60 days for payment
The process for requesting an organization determination is discussed in more detail in Chapter 9 of your Evidence of Coverage, “What to do if you have a problem or complaint (coverage decisions, appeals, complaints).” If you or your provider do not agree with the outcome of the initial organization determination, you or your provider may appeal the decision by requesting a reconsideration. This is also called a level 1 appeal.
Coverage Appeals
You can file an appeal if you do not agree with our organization determination. You must make your appeal request within 60 calendar days from the date on the written notice we send to answer your request for an organization determination. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.
You will receive a response from us on a level 1 appeal within:
- 72 hours for an expedited decision
- 30 days for pre-service
- 60 days for payment
If our plan says no to your level 1 appeal, we will forward the case file to the Independent Review Organization for a level 2 appeal. You will receive a response on a level 2 appeal from the Independent Review Organization within:
- 72 hours for an expedited appeal
- 30 days for pre-service
- 60 days for payment
If the Independent Review Organization says no to your appeal, you may be able to continue to a third level appeal with an Administrative Law Judge (ALJ). The dollar value of the coverage you are requesting must meet a minimum amount. If the dollar value of the coverage you are requesting is too low, you cannot make another appeal and the decision at level 2 is final. The notice you get from the Independent Review Organization will tell you if the dollar value of the coverage you are requesting is high enough to continue with the appeals process.
If the ALJ denies your appeal, then your case may be reviewed by the Medicare Appeals Council (MAC). If your case is reviewed and denied by the MAC, then the notice you get will tell you whether the rules allow you to go on to the fifth and final level of appeal. If the rules allow you to go on, the written notice will tell you who to contact and what to do next if you choose to continue with your appeal. The fifth level appeal is reviewed by a judge at the Federal District Court. This is the last stage of the administrative appeals process.
You, your prescribing health care provider or another person you name can file an appeal for you. The person you name would be your appointed representative. If you want some other person to act for you, you and that person must sign and date a statement that gives that person legal permission to act as your appointed representative.
- Coverage Determinations and Appeals — Medicare Prescription Drug Plans (Part D)
Coverage Determination Details
When you ask for a decision on your Part D prescription drug benefit, you are requesting a coverage determination.
If your health care provider or pharmacist tells you that we will not cover a prescription drug, or if you are charged more than you think your copayment or coinsurance should be, you or your provider may ask us or a coverage determination.
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 (PDF).
The following are examples of when you can ask us for a coverage determination:
- If there is a limit on the quantity (or dose) of a drug and you disagree with the limit
- If there is a requirement that you try another drug before we will pay for the drug you are asking for
- If the copayment for a drug is higher than expected
- If the drug is listed as non-formulary
When you request a coverage determination, you will receive a response from us within:
- 72 hours for a "standard" decision
- 24 hours, if you have asked for a "fast" decision, also called an expedited determination
The process for requesting a coverage determination is discussed in more detail in Chapter 7 of your Evidence of Coverage, “What to do if you have a problem or complaint (coverage decisions, appeals, complaints).”
If you or your provider do not agree with the outcome of the initial coverage determination, you or your provider may appeal the decision by requesting a coverage redetermination. This is also called a level 1 appeal.
Coverage Appeals
You can file an appeal if you do not agree with our coverage determination. You must make your appeal request within 60 calendar days from the date on the written notice we send to answer your request for a coverage determination. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal.
You will receive a response from us on a level 1 appeal within:
- Seven calendar days for a "standard" decision
- 72 hours, if you have asked for a "fast" decision
If our plan says no to your level 1 appeal, the written notice we send you will include instructions on how to make a level 2 appeal with the Independent Review Organization. These instructions will tell who can make this level 2 appeal, what deadlines you must follow and how to reach the review organization.
If the Independent Review Organization says no to your appeal, you may be able to continue to a third level appeal with an Administrative Law Judge (ALJ). The dollar value of the coverage you are requesting must meet a minimum amount. If the dollar value of the coverage you are requesting is too low, you cannot make another appeal and the decision at level 2 is final. The notice you get from the Independent Review Organization will tell you if the dollar value of the coverage you are requesting is high enough to continue with the appeals process.
If the ALJ denies your appeal, then your case may be reviewed by the Medicare Appeals Council (MAC). If your case is reviewed and denied by the MAC, then the notice you get will tell you whether the rules allow you to go on to the fifth and final level of appeal. If the rules allow you to go on, the written notice will tell you who to contact and what to do next if you choose to continue with your appeal. The fifth level appeal is reviewed by a judge at the Federal District Court. This is the last stage of the administrative appeals process.
You, your prescribing health care provider or another person you name can file an appeal for you. The person you name would be your appointed representative. If you want some other person to act for you, you and that person must sign and date a statement that gives that person legal permission to act as your appointed representative.
- Filing a Grievance
A grievance is any complaint other than one that involves an organization determination. You may file a grievance either orally or in writing, no later than 60 days after the event or incident that led to the grievance. You may file a grievance for a variety of reasons, including:
- Feeling that you are being encouraged to leave (dis-enroll from) your Medicare Health Plan.
- Problems getting an appointment.
- Disrespectful or rude behavior by providers or staff.
- Cleanliness or condition of a hospital or doctor's office
- Disagreeing with our decision not to give you a "fast" organization determination or appeal
You will receive a response within:
- 24 hours if your grievance involves a refusal to give you a "fast" organization determination or appeal.
- 30 calendar days for all other grievances. We may extend the timeline by up to 14 calendar days if you ask for an extension, or if we justify a need for additional information and the delay is in your best interest.
If you have a grievance, you can call Customer Service at 1-855-204-2744 (toll free), or TTY 711, during the hours of operation.
- From October 1 to March 31, the Customer Service hours are 8 a.m. to 8 p.m. Eastern Time, seven days a week.
- From April 1 to September 30, the Customer Service hours are 8 a.m. to 8 p.m. Eastern Time, Monday through Friday. Our automated phone system handles calls received after 8 p.m. and on Saturdays, Sundays and holidays.
You can also mail your grievance to:
BlueCross BlueShield of South Carolina Medicare Advantage
P.O. Box 100191
Columbia, SC 29202-3191Complaints about Quality of Care
If you have a complaint about the quality of care you received, such as about getting discharged from the hospital too soon, you may also complain to the Quality Improvement Organization (QIO).
KEPRO
5201 W. Kennedy Blvd., Suite 900
Tampa, FL 33609
Phone: 1-888-317-0751 TTY: 777
Web: www.keproqio.comFor a complete description of your appeal and grievance rights, please see your Evidence of Coverage.
Contact Medicare
If you have questions, call 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day, 7 days a week.
While we encourage you to contact Customer Service first when you have a grievance, you can also tell Medicare about your grievances directly by visiting the Centers for Medicare & Medicaid Services (CMS) website.