BlueCross Rx Value Forms

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

If you cannot find the form you need, call Customer Service toll-free at 1-888-645-6025. 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.

Prescription Mail Service Order Form

Coverage Determination Form

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 Rx Value is a stand-alone prescription drug plan with a Medicare contract. Enrollment in BlueCross Rx Value depends on contract renewal.

Last updated: 10/04/2019
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