BlueCross Total Value (PPO) Forms

The following are links to forms you might need as a member of your Medicare Advantage Plan.

If you cannot find the form you need, call Customer Service toll-free at 1-855-204-2744. TTY users should call 711. We are available 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. From Oct. 1 through Mar. 31, we are available 8 a.m. to 8 p.m., Eastern Time, seven days a week.

Customer Service has free language interpreter services available for non-English speakers.

Medical/Dental Claim Form

Reconsideration Request Form

Prescription Mail Service Order Form

Drug Coverage Determination Form

Drug Coverage Redetermination Form

Prescription Drug Claim Form

Enrollment Form

Authorization To Disclose Protected Health Information To A Third Party

Appointment of Representative Form

Thank you for choosing BlueCross BlueShield of South Carolina!

BlueCross Total Value is a PPO plan with a Medicare contract. Enrollment in BlueCross Total depends on contract renewal.

Last updated: 04/29/2021