Medical

Health Benefits Claim Form
State Health Plan Comprehensive Benefits Claim Form
COVID-19 At-Home Test Reimbursement Form

Dental

If your plan includes coverage for dental services, use these forms to file claims:

Dental Services Claim Form - Columbia Service Center
Dental Services Claim Form - Greenville Service Center
Dental Services Claim Form State Dental Plan

Vision

If your plan includes coverage for vision services, you may need one of these forms to file your claims:

Vision Benefits Claim Form - Columbia Service Center
Vision Benefits Claim Form - Greenville Service Center
Healthy Vision Out-of-Network Claim Form

Prescription Drug

Many of our plans include pharmacy and prescription drug benefits. If yours does, you’ll save money at the point of purchase when you use a network pharmacy.

There may be times when you need to file a claim. Examples include:

• You paid 100 percent for a covered medication.
• You didn’t show your member ID when you filled a prescription.
• You filled a prescription for a covered medication at a non-participating pharmacy.

In these cases, use the Prescription Drug Claim Form.

If you regularly take medication, you may also want to look into our mail-order service. With this benefit, you can order up to a 90-day supply of your prescriptions. Use the Prescription Drug Mail Service Form.

Medicare Supplement

When filing a Medicare Supplement claim, follow these steps:

1. Write your BlueCross BlueShield of South Carolina ID number on your Medicare Summary Notice.
2. Make a copy of all pages and mail them to us at:

BlueCross BlueShield of South Carolina
Consumer Products, AF-525
P.O. Box 100133
Columbia, SC 29202-3133

Medicare prescription drug claims

If your Medicare Supplement policy has prescription drug coverage (Plans H and I), please send us copies of your drug receipts or a printout from your pharmacy. Include your BlueCross ID number. Mail these items to us at the above address.