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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.

Results

Year Links
2019 BlueCross Total PPO MAPD Formulary (Updated 8/5/2019) (PDF) BlueCross Total PPO,BlueCross Secure HMO Comprehensive Formulary (PDF) do-not-filter 2019
2019 BlueCross Secure HMO MAPD Formulary (Updated 8/5/2019) (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 do-not-filter 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 8/5/2019) (PDF) BlueCross Value Rx Comprehensive Formulary (PDF) do-not-filter 2019
2019 BlueCross RxPlus Comprehensive Formulary (Updated 8/5/2019) (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 Prescription Drug Transition Policy (PDF) BlueCross Total PPO,BlueCross Secure HMO,BlueCross Value Rx,BlueCross Plus Rx Transition Policy 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 Miscellaneous do-not-filter 2019
2019 BlueCross RX Plus Pharmacy Directory do-not-filter Miscellaneous do-not-filter 2019
MAPD June 2019 PA Criteria Update do-not-filter Prior Authorization Criteria - Rx Plus/Rx Value (Plan type) do-not-filter 2019
PDP June 2019 PA Criteria Update do-not-filter Prior Authorization Criteria - Rx Plus/Rx Value (Plan type) do-not-filter 2019
PY2019 MAPD April 2019 ST Criteria Update do-not-filter Prior Authorization Criteria - Rx Plus/Rx Value (Plan type) do-not-filter 2019
MAPD Formulary Change Notice - July 2019 do-not-filter Formulary Change Notice do-not-filter 2019
PDP Formulary Change Notice - July 2019 do-not-filter Formulary Change Notice do-not-filter 2019

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 organization 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.

For assistance current members should call Customer Service at 1-888-645-6025. If you are not a member, call 1-800-930-2836 (calling this number will connect you to a licensed agent). TTY users, call 711. Calls to these numbers are free. We are available for phone calls 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 October 1, 2017 through February 14, 2018, we are available 8 a.m. to 8 p.m., Eastern Time, seven days a week.

Existing Medicare Supplement members with questions should call 800-868-2500 extension 46401.

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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