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General Medicare Documents and Forms

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

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Blue Select Hospital Directory Supplement Medicare Select Hospital Directory do-not-filter 2018
2019 BlueCross Total PPO MAPD Formulary (Updated 11/1/2019) (PDF) BlueCross Total PPO,BlueCross Secure HMO Comprehensive Formulary (PDF) do-not-filter 2019
2019 BlueCross Secure HMO MAPD Formulary (Updated 11/1/2019) (PDF) BlueCross Total PPO,BlueCross Secure HMO Comprehensive Formulary (PDF) do-not-filter 2019
2019 BlueCross HMO Summary of Benefits (PDF) BlueCross Secure HMO Summary of Benefits (PDF) do-not-filter 2019
2019 BlueCross PPO Summary of Benefits (PDF) BlueCross Total PPO Summary of Benefits (PDF) do-not-filter 2019
2019 BlueCross Total Upstate PPO Evidence of Coverage (PDF) BlueCross Total PPO Evidence of Coverage (PDF) do-not-filter 2019
2019 BlueCrossTotal Midlands Coastal PPO Evidence of Coverage (PDF) BlueCross Total PPO Evidence of Coverage (PDF) do-not-filter 2019
2019 BlueCross Total Lowcountry PPO Evidence of Coverage (PDF) BlueCross Total PPO Evidence of Coverage (PDF) do-not-filter 2019
2019 BlueCross Secure Greenville HMO Evidence of Coverage (PDF) BlueCross Secure HMO Evidence of Coverage (PDF) do-not-filter 2019
2019 BlueCross Secure Richland HMO Evidence of Coverage (PDF) BlueCross Secure HMO Evidence of Coverage (PDF) do-not-filter 2019
2019 BlueCross Secure Richland HMO Provider Directory (PDF) BlueCross Secure HMO Provider Directory do-not-filter 2019
2019 BlueCross Secure Greenville HMO Provider Directory (PDF) BlueCross Secure HMO Provider Directory do-not-filter 2019
2019 BlueCross PPO Provider Directory BlueCross Total PPO Provider Directory do-not-filter 2019
2019 BlueCross MAPD Total Pharmacy Directory BlueCross Total PPO Pharmacy Directory do-not-filter 2019
2019 BlueCross MAPD Secure Pharmacy Directory BlueCross Secure HMO Pharmacy Directory ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2019
2019 ANOC RxValue (PDF) BlueCross Value Rx Annual Notice of Change & Evidence of Coverage do-not-filter 2019
2019 EOC RxValue (PDF) BlueCross Value Rx Annual Notice of Change & Evidence of Coverage do-not-filter 2019
2019 ANOC RxPlus (PDF) BlueCross Plus Rx Annual Notice of Change & Evidence of Coverage do-not-filter 2019
2019 EOC RxPlus (PDF) BlueCross Plus Rx Annual Notice of Change & Evidence of Coverage do-not-filter 2019
2019 BlueCross RxValue Comprehensive Formulary (Updated 11/1/2019) (PDF) BlueCross Value Rx Comprehensive Formulary (PDF) do-not-filter 2019
2019 BlueCross RxPlus Comprehensive Formulary (Updated 11/1/2019) (PDF) BlueCross Plus Rx Comprehensive Formulary (PDF) do-not-filter 2019
2019 Rx Coverage Determination (PDF) BlueCross Value Rx,BlueCross Plus Rx Coverage Determination do-not-filter 2019
2019 Rx Coverage Redetermination (PDF) BlueCross Value Rx,BlueCross Plus Rx Coverage Redetermination do-not-filter 2019
2019 BlueCross Value Rx and 2019 BlueCross Plus Rx Plan Rating (PDF) BlueCross Value Rx,BlueCross Plus Rx Plan Rating do-not-filter 2019
2019 Prescription Drug Transition Policy (PDF) BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx General Transition Notice do-not-filter 2019
PDP LIS Summary Table BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) do-not-filter 2019
2019 Summary of Benefits Rx Value and Rx Plus (PDF) BlueCross Value Rx,BlueCross Plus Rx Summary of Benefits (PDF) do-not-filter 2019
Prescription drug claim form (PDF) BlueCross Value Rx,BlueCross Plus Rx Prescription drug claim form do-not-filter 2019
2019 BlueCross BlueShield Medicare Advantage /PDP PHI Disclosure Form (PDF) BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx PHI Disclosure Form do-not-filter 2019
Appointment of representative form (PDF) BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx Appointment of representative form do-not-filter 2019
2019 BlueCross HMO MAPD Enrollment Instructions (PDF) BlueCross Secure HMO Enrollment Form Instructions do-not-filter 2019
2019 BlueCross PPO MAPD Enrollment Instructions (PDF) BlueCross Total PPO Enrollment Form Instructions do-not-filter 2019
2019 BlueCross Rx Value and Rx Plus PDP Enrollment Instructions (PDF) BlueCross Value Rx,BlueCross Plus Rx Enrollment Form Instructions do-not-filter 2019
2019 BlueCross Rx Value and Rx Plus Enrollment Application (PDF) BlueCross Value Rx,BlueCross Plus Rx Enrollment Form do-not-filter 2019
2019 BlueCross Total PPO MAPD Enrollment Application (PDF) BlueCross Total PPO Enrollment Form do-not-filter 2019
2019 BlueCross Secure HMO MAPD Enrollment Application (PDF) BlueCross Secure HMO Enrollment Form do-not-filter 2019
Medicare Advantage (Medical) claim form (PDF) BlueCross Total PPO,BlueCross Secure HMO Health claim form do-not-filter 2019
Medicare Advantage Grievance Information BlueCross Total PPO,BlueCross Secure HMO Grievance Information do-not-filter 2019
Prescription Drug Grievance Information BlueCross Value Rx,BlueCross Plus Rx Grievance Information do-not-filter 2019
2019 Medicare Extra Help Program BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx Extra Help Program do-not-filter 2019
2019 Medicare Therapy Management Program BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx Medicare Therapy Management Program do-not-filter 2019
OON Drug Coverage Rules BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx Out Of Network Coverage Rules do-not-filter 2019
2019 Prescription Drug Mail Order Form BlueCross Value Rx,BlueCross Plus Rx Mail Order Form do-not-filter 2019
2019 Rights and Responsibilities Upon Disenrollment BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx Disenrollment do-not-filter 2019
MAPD Out of Network Coverage Rules BlueCross Total PPO,BlueCross Secure HMO Out Of Network Coverage Rules do-not-filter 2019
Coverage Decision and Appeal Information MA BlueCross Total PPO,BlueCross Secure HMO Coverage Determination do-not-filter 2019
Cov Determination and Appeals Information (Pharmacy) BlueCross Value Rx,BlueCross Plus Rx Coverage Determination do-not-filter 2019
BC Total LIS Summary BlueCross Total PPO Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) do-not-filter 2019
BC Secure LIS Summary BlueCross Secure HMO Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) do-not-filter 2019
BC Total Star Ratings BlueCross Total PPO Plan Rating (PDF) do-not-filter 2019
BC Secure Star Ratings BlueCross Total PPO Plan Rating (PDF) do-not-filter 2019
BC Total ANOC Upstate BlueCross Total PPO Annual Notice of Change & Evidence of Coverage do-not-filter 2019
BC Total ANOC Lowcountry BlueCross Total PPO Annual Notice of Change & Evidence of Coverage do-not-filter 2019
BC Total ANOC Midlands/Coastal BlueCross Total PPO Annual Notice of Change & Evidence of Coverage do-not-filter 2019
BC Secure Richland ANOC BlueCross Secure HMO Annual Notice of Change & Evidence of Coverage do-not-filter 2019
BC Secure Greenville ANOC BlueCross Secure HMO Annual Notice of Change & Evidence of Coverage do-not-filter 2019
2019 Rx Medicare Extra Help Program BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx Extra Help Program do-not-filter 2019
OON Dental Claim Form BlueCross Total PPO,BlueCross Secure HMO Dental Claim Form do-not-filter 2019
2019 MAPD Rights and Responsibilities Upon Disenrollment do-not-filter Disenrollment do-not-filter 2019
2019 Rx Rights and Responsibilities Upon Disenrollment do-not-filter Disenrollment do-not-filter 2019
2019 BlueCross RX Value Pharmacy Directory do-not-filter Pharmacy Directory ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2019
2019 BlueCross RX Plus Pharmacy Directory do-not-filter Pharmacy Directory do-not-filter 2019
Blue Select Hospital Directory do-not-filter Medicare Select Hospital Directory do-not-filter 2018
MAPD November 2019 PA Criteria Update do-not-filter Prior Authorization Criteria - Rx Plus/Rx Value (Plan type) do-not-filter 2019
PY2019 MAPD August 2019 ST Criteria Update do-not-filter Prior Authorization Criteria - Rx Plus/Rx Value (Plan type) do-not-filter 2019
PDP November 2019 PA Criteria Update do-not-filter Prior Authorization Criteria - Rx Plus/Rx Value (Plan type) do-not-filter 2019
MAPD Formulary Change Notice - October 2019 do-not-filter Formulary Change Notice do-not-filter 2019
PDP Formulary Change Notice - October 2019 do-not-filter Formulary Change Notice do-not-filter 2019
2019 Fall Events do-not-filter Miscellaneous do-not-filter 2019
Prescription Drug Grievance Information BlueCross Value Rx,BlueCross Plus Rx Miscellaneous ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
Medicare Advantage Grievance Information BlueCross Total PPO,BlueCross Secure HMO Miscellaneous ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
Medicare Advantage Grievance Information BlueCross Total PPO,BlueCross Secure HMO Miscellaneous do-not-filter 2019
Coverage Decision and Appeal Information MA BlueCross Total PPO,BlueCross Secure HMO Miscellaneous do-not-filter 2019
OON Drug Coverage Rules do-not-filter Miscellaneous do-not-filter 2019
2020 BlueCross Secure Summary of Benefits (PDF) BlueCross Secure HMO Summary of Benefits (PDF) do-not-filter 2020
2020 BlueCross Total Summary of Benefits (PDF) BlueCross Total PPO Summary of Benefits (PDF) do-not-filter 2020
2020 BlueCross Total Upstate PPO Evidence of Coverage (PDF) BlueCross Total PPO Evidence of Coverage (PDF) do-not-filter 2020
2020 BlueCrossTotal Midlands Coastal PPO Evidence of Coverage (PDF) BlueCross Total PPO Evidence of Coverage (PDF) do-not-filter 2020
2020 BlueCross Total Lowcountry PPO Evidence of Coverage (PDF) BlueCross Total PPO Evidence of Coverage (PDF) do-not-filter 2020
2020 BlueCross Secure Greenville HMO Evidence of Coverage (PDF) BlueCross Secure HMO Evidence of Coverage (PDF) do-not-filter 2020
2020 BlueCross Secure Richland HMO Evidence of Coverage (PDF) BlueCross Secure HMO Evidence of Coverage (PDF) do-not-filter 2020
2020 BlueCross Secure Richland HMO Provider Directory (URL) BlueCross Secure HMO Miscellaneous do-not-filter 2020
2020 BlueCross Secure Greenville HMO Provider Directory (URL) BlueCross Secure HMO Miscellaneous do-not-filter 2020
2020 BlueCross Total Provider Directory (URL) BlueCross Total PPO Provider Directory ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 Secure/Total Pharmacy Directory BlueCross Total PPO,BlueCross Secure HMO Pharmacy Directory do-not-filter 2020
2020 BlueCross Rx Value EOC (PDF) BlueCross Value Rx Evidence of Coverage (PDF) ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 BlueCross Rx Plus EOC (PDF) BlueCross Plus Rx Evidence of Coverage (PDF) ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 Rx Value/Rx Plus Pharmacy Directory (PDF) BlueCross Value Rx,BlueCross Plus Rx Pharmacy Directory ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 Rx Value/Rx Plus Coverage Determinations and Redeterminations (PDF) BlueCross Value Rx,BlueCross Plus Rx Miscellaneous do-not-filter 2020
2020 Rx Coverage Determination Form (PDF) BlueCross Value Rx,BlueCross Plus Rx Coverage Determination ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 Rx Coverage Redetermination Form (PDF) BlueCross Value Rx,BlueCross Plus Rx Coverage Redetermination ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
BlueCross Rx Value and Rx Plus Plan Rating (PDF) BlueCross Value Rx,BlueCross Plus Rx Plan Rating do-not-filter 2020
2020 Rx Prescription Drug Transition Policy (PDF) BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx General Transition Notice do-not-filter 2020
2020 Rx Value/Rx Plus LIS Summary BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) do-not-filter 2020
2020 Rx Value and Rx Plus Summary of Benefits(PDF) BlueCross Value Rx,BlueCross Plus Rx Summary of Benefits (PDF) do-not-filter 2020
2020 BlueCross BlueShield Medicare Advantage/Rx PHI Disclosure Form (PDF) BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx PHI Disclosure Form ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
Appointment of Representative Form (PDF) BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx Appointment of representative form ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 BlueCross Secure HMO Enrollment Instructions (PDF) BlueCross Secure HMO Enrollment Form Instructions do-not-filter 2020
2020 BlueCross Total PPO Enrollment Instructions (PDF) BlueCross Total PPO Enrollment Form Instructions ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 BlueCross Rx Value and Rx Plus Enrollment Instructions (PDF) BlueCross Value Rx,BlueCross Plus Rx Enrollment Form Instructions ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 BlueCross Rx Value and Rx Plus Enrollment Application (PDF) BlueCross Value Rx,BlueCross Plus Rx Enrollment Form ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 BlueCross Total PPO MAPD Enrollment Application (PDF) BlueCross Total PPO Enrollment Form ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 BlueCross Secure HMO MAPD Enrollment Application (PDF) BlueCross Secure HMO Enrollment Form do-not-filter 2020
Medicare Advantage (Medical) claim form (PDF) BlueCross Total PPO,BlueCross Secure HMO Health claim form ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 Medicare Extra Help Program BlueCross Total PPO,BlueCross Secure HMO Extra Help Program ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 Medicare Therapy Management Program BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx Medicare Therapy Management Program ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
OON Drug Coverage Rules BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx Miscellaneous do-not-filter 2020
2020 Rights and Responsibilities Upon Disenrollment BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx Disenrollment ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
MAPD Out of Network Coverage Rules BlueCross Total PPO,BlueCross Secure HMO Out Of Network Coverage Rules ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
MA Coverage Decision and Appeal Information BlueCross Total PPO,BlueCross Secure HMO Miscellaneous do-not-filter 2020
BlueCross Total LIS Summary BlueCross Total PPO Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) do-not-filter 2020
BlueCross Secure LIS Summary BlueCross Secure HMO Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) do-not-filter 2020
BlueCross Total Star Ratings BlueCross Total PPO Plan Rating do-not-filter 2020
BlueCross Secure Star Ratings BlueCross Secure HMO Plan Rating do-not-filter 2020
2020 BlueCross Total Upstate ANOC BlueCross Total PPO Annual Notice of Change & Evidence of Coverage do-not-filter 2020
2020 BlueCross Total Lowcountry ANOC BlueCross Total PPO Annual Notice of Change & Evidence of Coverage do-not-filter 2020
2020 BlueCross Total Midlands/Coastal ANOC BlueCross Total PPO Annual Notice of Change & Evidence of Coverage do-not-filter 2020
2020 BlueCross Secure Richland ANOC BlueCross Secure HMO Annual Notice of Change & Evidence of Coverage do-not-filter 2020
2020 BlueCross BC Secure Greenville ANOC BlueCross Secure HMO Annual Notice of Change & Evidence of Coverage do-not-filter 2020
2020 Rx Medicare Extra Help Program BlueCross Value Rx,BlueCross Plus Rx Extra Help Program ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
PY2019 PDP August 2019 ST Criteria Update BlueCross Rx Plus, BlueCross Rx Value, BlueCross Value Rx,BlueCross Plus Rx, Select Step Therapy Criteria ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2019
2020 MA Transition Policy (PDF) BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx Transition Policy ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 Total/Secure Comprehensive Formulary (PDF) BlueCross Total PPO,BlueCross Secure HMO Comprehensive Formulary (PDF) ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 BlueCross RxValue Comprehensive Formulary (PDF) BlueCross Value Rx , BlueCross Value Rx Comprehensive Formulary (PDF) ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 BlueCross RxPlus Comprehensive Formulary (PDF) BlueCross Plus Rx Comprehensive Formulary (PDF) ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 Prescription drug claim form (PDF) BlueCross Value Rx,BlueCross Plus Rx Prescription drug claim form ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 Prescription Drug Mail Order Form (PDF) BlueCross Value Rx,BlueCross Plus Rx Mail Order Form ABBEVILLE, AIKEN, ALLENDALE, ANDERSON, BAMBERG, BARNWELL, BEAUFORT, BERKELEY, CALHOUN, CHARLESTON, CHEROKEE, CHESTER, CHESTERFIELD, CLARENDON, COLLETON, DARLINGTON, DILLON, DORCHESTER, EDGEFIELD, FAIRFIELD, FLORENCE, GEORGETOWN, GREENVILLE, GREENWOOD, HAMPTON, HORRY, JASPER, KERSHAW, LANCASTER, LAURENS, LEE, LEXINGTON, MARION, MARLBORO, MCCORMICK, NEWBERRY, OCONEE, ORANGEBURG, PICKENS, RICHLAND, SALUDA, SPARTANBURG, SUMTER, UNION, WILLIAMSBURG, YORK 2020
2020 BlueCross Rx Step Therapy Criteria do-not-filter BlueCross Rx Step Therapy Criteria do-not-filter 2020
2020 BlueCross Rx Prior Authorization Criteria do-not-filter BlueCross Rx Prior Authorization Criteria do-not-filter 2020
2020 BlueCross MAPD Prior Authorization Criteria do-not-filter BlueCross MAPD Prior Authorization Criteria do-not-filter 2020
2020 BlueCross MAPD Step Therapy Criteria do-not-filter BlueCross MAPD Step Therapy Criteria do-not-filter 2020

Medicare beneficiaries may also enroll in BlueCross Total (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 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, 2019, to Mar. 31, 2020.  Monday – Friday, 8 a.m. to 8 p.m. all other times.

If you are not a member, call us at 1-800-930-2836 (TTY users should call 711). We are available for phone calls from October 1 to December 31; you can call us 8 a.m. to 8 p.m., 7 days a week. From January 1 to September 30, we’re here 8 a.m. to 6 p.m., Monday through Friday. Calls to this number are answered by a licensed insurance agent.

BlueCare and Blue Select are not connected with or endorsed by the U.S. Government or the Federal Medicare Program. These policies have limitations and exclusions.

Last Updated Date: 10.1.2018
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