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Call us at 1-800-930-2836 (TTY 711)

General Medicare Documents and Forms

Find Medicare Forms

Looking for a plan document or a certain form? All CMS required documents are included below.

Results

Year Links
Prescription Drug Grievance Information BlueCross Plus Rx, BlueCross Rx Plus, BlueCross Rx Value, BlueCross Value Rx , BlueCross Value Rx Miscellaneous do-not-filter 2021
Prescription drug claim form (PDF) BlueCross Plus Rx, BlueCross Rx Plus, BlueCross Rx Value, BlueCross Value Rx , BlueCross Value Rx Prescription drug claim form do-not-filter 2021
OON Drug Coverage Rules BlueCross Value Rx,BlueCross Plus Rx,BlueCross Total PPO,BlueCross Secure HMO Out Of Network Coverage Rules do-not-filter 2021
Medicare Advantage Grievance Information BlueCross Total PPO,BlueCross Secure HMO Grievance Information do-not-filter 2021
Medicare Advantage (Medical) claim form (PDF) BlueCross Total PPO,BlueCross Secure HMO Health claim form do-not-filter 2021
MAPD Out of Network Coverage Rules BlueCross Total PPO,BlueCross Secure HMO Out Of Network Coverage Rules do-not-filter 2021
BlueCross Total Star Ratings BlueCross Total PPO Plan Rating do-not-filter 2021
BlueCross Total LIS Summary BlueCross Total PPO Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) do-not-filter 2021
BlueCross Total Value LIS Summary BlueCross Total Value PPO Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) do-not-filter 2021
BlueCross Secure Star Ratings BlueCross Secure HMO Plan Rating do-not-filter 2021
BlueCross Secure LIS Summary BlueCross Secure HMO Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) do-not-filter 2021
Appointment of Representative Form (PDF) BlueCross Value Rx,BlueCross Plus Rx,BlueCross Total PPO,BlueCross Secure HMO Appointment of representative form do-not-filter 2021
2021 Rx Value/Rx Plus Pharmacy Directory (PDF) BlueCross Plus Rx, BlueCross Rx Plus, BlueCross Rx Value, BlueCross Value Rx , BlueCross Value Rx, BlueCross Value Rx,BlueCross Plus Rx Pharmacy Directory do-not-filter 2021
2021 Rx Value/Rx Plus LIS Summary BlueCross Plus Rx, BlueCross Rx Plus, BlueCross Rx Value, BlueCross Value Rx , BlueCross Value Rx Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) do-not-filter 2021
2021 Rx Value/Rx Plus Coverage Determinations and Redeterminations (PDF) BlueCross Plus Rx, BlueCross Rx Plus, BlueCross Rx Value, BlueCross Value Rx , BlueCross Value Rx Determination and Redetermination Policy do-not-filter 2021
2021 Rx Value and Rx Plus Summary of Benefits(PDF) BlueCross Plus Rx, BlueCross Rx Plus, BlueCross Rx Value, BlueCross Value Rx , Rx Summary of Benefits (PDF) do-not-filter 2021
2021 Rx Prescription Drug Transition Policy (PDF) BlueCross Value Rx,BlueCross Plus Rx,BlueCross Total PPO,BlueCross Secure HMO Transition Policy do-not-filter 2021
2021 Rx Medicare Extra Help Program BlueCross Plus Rx, BlueCross Rx Plus, BlueCross Rx Value, BlueCross Value Rx , BlueCross Value Rx, BlueCross Value Rx,BlueCross Plus Rx Extra Help Program do-not-filter 2021
2021 Rx Coverage Redetermination Form (PDF) BlueCross Value Rx,BlueCross Plus Rx Coverage Redetermination do-not-filter 2021
2021 Rx Coverage Determination Form (PDF) BlueCross Value Rx,BlueCross Plus Rx Coverage Determination do-not-filter 2021
2021 Prescription Drug Mail Order Form (PDF) BlueCross Plus Rx, BlueCross Rx Plus, BlueCross Rx Value, BlueCross Value Rx , BlueCross Value Rx Mail Order Form do-not-filter 2021
2021 Medicare Therapy Management Program BlueCross Plus Rx, BlueCross Rx Plus, BlueCross Rx Value, BlueCross Value Rx , BlueCross Value Rx Medicare Therapy Management Program do-not-filter 2021
2021 Medicare Extra Help Program BlueCross Total PPO,BlueCross Secure HMO Extra Help Program do-not-filter 2021
2021 MA Transition Policy (PDF) BlueCross Value Rx,BlueCross Plus Rx,BlueCross Total PPO,BlueCross Secure HMO Transition Policy do-not-filter 2021
2021 BlueCross Total Upstate ANOC BlueCross Total PPO Annual Notice of Change & Evidence of Coverage do-not-filter 2021
2021 BlueCross Total Summary of Benefits (PDF) BlueCross Total PPO Summary of Benefits (PDF) do-not-filter 2021
2021 BlueCross Total Value Summary of Benefits (PDF) BlueCross Total Value PPO Summary of Benefits (PDF) do-not-filter 2021
2021 BlueCross Total/Total Value Provider Directory (URL) BlueCross Total PPO, BlueCross Total Value PPO, BlueCross Total Value PPO Provider Directory do-not-filter 2021
2021 BlueCross Total/Total Value Provider Directory (pdf) BlueCross Total PPO Provider Directory do-not-filter 2021
2021 BlueCross Total PPO Enrollment Application (PDF) BlueCross Total PPO Enrollment Form do-not-filter 2021
2021 BlueCross Total Value PPO Enrollment Application (PDF) BlueCross Total PPO Enrollment Form do-not-filter 2021
2021 BlueCross Secure Summary of Benefits (PDF) BlueCross Secure HMO Summary of Benefits (PDF) do-not-filter 2021
2021 BlueCross Secure HMO Provider Directory (pdf) BlueCross Secure HMO Provider Directory do-not-filter 2021
2021 BlueCross Secure HMO MAPD Enrollment Application (PDF) BlueCross Secure HMO Enrollment Form do-not-filter 2021
2021 BlueCross Rx Value and Rx Plus Enrollment Application (PDF) BlueCross Plus Rx, BlueCross Rx Plus, BlueCross Rx Value, BlueCross Value Rx , BlueCross Value Rx, BlueCross Value Rx,BlueCross Plus Rx Enrollment Form do-not-filter 2021
2021 BlueCross BlueShield Medicare Advantage/Rx PHI Disclosure Form (PDF) BlueCross Value Rx,BlueCross Plus Rx,BlueCross Total PPO,BlueCross Secure HMO PHI Disclosure Form do-not-filter 2021
2021 BlueCross Secure HMO Provider Directory (URL) BlueCross Secure HMO Provider Directory do-not-filter 2021
BlueCross Rx Value and Rx Plus Plan Rating (PDF) BlueCross Plus Rx, BlueCross Rx Plus, BlueCross Rx Value, BlueCross Value Rx , BlueCross Value Rx Star Rating do-not-filter 2021
2021 PDP Star Ratings do-not-filter Star Rating do-not-filter 2021
2021 MAPD Pharmacy Directory do-not-filter Pharmacy Directory do-not-filter 2021
2021 BlueCross Secure Greenville EOC do-not-filter Evidence of Coverage (PDF) do-not-filter 2021
2021 BlueCross Secure Richland EOC do-not-filter Evidence of Coverage (PDF) do-not-filter 2021
2021 BlueCross Rx Plus (PDP) EOC do-not-filter Evidence of Coverage (PDF) do-not-filter 2021
Rx Plus 2021 Formulary do-not-filter Comprehensive Formulary (PDF) do-not-filter 2021
2021 PDP Pharmacy Directory do-not-filter Pharmacy Directory do-not-filter 2021
2021 BlueCross Rx Value (PDP) EOC do-not-filter Evidence of Coverage (PDF) do-not-filter 2021
Rx Value 2021 Formulary do-not-filter Comprehensive Formulary (PDF) do-not-filter 2021
2021 Total/Secure Comprehensive Formulary do-not-filter Comprehensive Formulary (PDF) do-not-filter 2021
2021 Total Value Comprehensive Formulary do-not-filter Comprehensive Formulary (PDF) do-not-filter 2021
2021 Total Lowcountry EOC do-not-filter Evidence of Coverage (PDF) do-not-filter 2021
2021 Total Midlands-Coastal EOC do-not-filter Evidence of Coverage (PDF) do-not-filter 2021
2021 Total Upstate EOC do-not-filter Evidence of Coverage (PDF) do-not-filter 2021
2021 Total Value Midlands-Coastal EOC do-not-filter Evidence of Coverage (PDF) do-not-filter 2021
2021 Total Value Upstate EOC do-not-filter Evidence of Coverage (PDF) do-not-filter 2021
2021 BlueCross MAPD Prior Authorization Criteria do-not-filter BlueCross MAPD Prior Authorization Criteria do-not-filter 2021
2021 MAPD PA Criteria do-not-filter BlueCross MAPD Prior Authorization Criteria do-not-filter 2021
2021 MAPD ST Criteria do-not-filter Step Therapy Criteria do-not-filter 2021
2021 PDP ST Criteria do-not-filter Step Therapy Criteria do-not-filter 2021
2021 PDP PA Criteria do-not-filter BlueCross Rx Prior Authorization Criteria do-not-filter 2021
2021 A HiG L N Blue Select Outline do-not-filter Outline of Coverage "OOC" (pdf) do-not-filter 2021
2021 A C F HiF Blue Select Outline do-not-filter Outline of Coverage "OOC" (pdf) do-not-filter 2021
2021 A K BlueCare Outline do-not-filter Outline of Coverage "OOC" (pdf) do-not-filter 2021
2021 A K Blue Select Outline do-not-filter Outline of Coverage "OOC" (pdf) do-not-filter 2021
2021 A B D G BlueCare Outline do-not-filter Outline of Coverage "OOC" (pdf) do-not-filter 2021
2021 A C F HiF BlueCare Outline do-not-filter Outline of Coverage "OOC" (pdf) do-not-filter 2021
2021 A B D G Blue Select Outline do-not-filter Outline of Coverage "OOC" (pdf) do-not-filter 2021
2021 A HiG L N BlueCare Outline do-not-filter Outline of Coverage "OOC" (pdf) do-not-filter 2021
2021 Choose a MediGap policy do-not-filter Choose a Medigap Policy do-not-filter 2021
2021 BlueCross Total Value PPO Step Therapy Criteria (PDF) do-not-filter Step Therapy Criteria do-not-filter 2021
2021 BlueCross Total Value Prior Authorization Criteria (PDF) do-not-filter Prior Authorization Criteria do-not-filter 2021

Medicare beneficiaries may also enroll in BlueCross Total (PPO), BlueCross Total Value (PPO), BlueCross Secure (HMO), BlueCross Rx Value (PDP) and BlueCross Rx Plus (PDP) through the CMS Online Enrollment Center at www.medicare.gov.

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

You must continue to pay your Part B premium. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply.  Benefits, premiums, copayments or 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.

Current members should call Customer Service at 1-855-204-2744 for additional information. (TTY users should call 711). Hours are seven days a week, 8 a.m. to 8 p.m., Oct. 1 to Mar. 31.  Monday – Friday, 8 a.m. to 8 p.m. all other times.