If you or a family member have coverage through South Carolina Healthy Connections Medicaid, you may receive a review form soon. Learn how to keep your benefits on our
South Carolina Medicaid: Documents and forms
Find the documents and forms Humana Healthy Horizons® in South Carolina members need to get the most from their enrollment.
Key plan documents
Welcome Kit
All new members get a welcome kit in the mail. You also can view it below. Your welcome kit includes the information you need at the start of your enrollment in Humana Healthy Horizons in South Carolina.
Welcome Kit – English
Welcome Kit – Spanish
Caregiver’s Toolkit – English
Caregiver’s Toolkit – Spanish
Health Risk Assessment
The answers you give us on your HRA help us make sure you get the care you need. Your welcome kit includes a Health Risk Assessment (HRA) Form and postage-paid envelope in which to return your completed HRA. You also can download a HRA below.
Health Risk Assessment (HRA) Form – English
Health Risk Assessment (HRA) Form – Spanish
Your welcome kit includes information about the many ways you can return your completed HRA to us.
Member Handbook
Have questions about your plan, benefits, and covered services? Check out your Member Handbook.
Comprehensive Drug List
The Comprehensive Drug List is a list of drugs and medicine your plan covers. Your doctor can prescribe you drugs and medicine on this list if needed. We update our Comprehensive Drug List periodically during the year. If we update the Comprehensive Drug List, we will notify you and we will make the new version available below.
Comprehensive Drug List – English
Comprehensive Drug List – Spanish
Comprehensive Drug List changes – English
Comprehensive Drug List changes – Spanish
Provider Directories
Refer to the Provider Directory in the region where you live to find information about in-network doctors, specialists, healthcare facilities, and more. You also can use our Find Care
Region 1 – Abbeville, Anderson, Cherokee, Edgefield, Greenville, Greenwood, Laurens, McCormick, Oconee, Pickens, Saluda and Spartanburg
- Provider Directory – English and Spanish (Part 1 of 4)
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Region 2 – Aiken, Allendale, Bamberg, Barnwell, Calhoun, Chester, Clarendon, Fairfield, Kershaw, Lancaster, Lee, Lexington, Newberry, Orangeburg, Richland, Sumter, Union and York
- Provider Directory – English and Spanish (Part 1 of 3)
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pdf opens in new window - Provider Directory- English and Spanish (Part 3 of 3)
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Region 3 – Beaufort, Berkeley, Charleston, Chesterfield, Colleton, Darlington, Dillon, Dorchester, Florence, Georgetown, Hampton, Horry, Jasper, Marion, Marlboro and Williamsburg
- Provider Directory – English and Spanish (Part 1 of 3)
pdf opens in new window - Provider Directory – English and Spanish (Part 2 of 3)
pdf opens in new window - Provider Directory – English and Spanish (Part 3 of 3)
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Primary Care Provider Change Request Form
Grievance and Appeal Forms
We want you to be happy with the care you get. We hope you get the best care possible.
If you are not happy with any part of your healthcare plan, Member Services, your doctor or a facility, you can send in a grievance
You also can appeal a claim or a denied service using Grievance and Appeal Forms
If you are sending an appeal or grievance for another covered member, be sure to fill out an Appointment of Representative Form
Legal and privacy notices
The legal and privacy notices below provide information about:
- How Humana uses, and when we might share, your personal information
- Your privacy rights
Individual privacy rights (English and Spanish)
Rights and responsibilities Form – English
Rights and responsibilities Form – Spanish
HIPAA privacy notice Form – English
HIPAA privacy notice Form – Spanish
To give us permission to share your medical information with someone, you must complete and send back to us a Consent for Release of Medical Information Form and a Consent for Release of Protected Health Information Form.
Consent for Release of Medical Information Form – English and Spanish
Consent for Release of Protected Health Information Form – English
Consent for Release of Protected Health Information Form – Spanish
Detecting, Preventing, and Reporting Healthcare Fraud
Notice of Non-Discrimination
Humana Inc. and its subsidiaries comply with applicable Federal civil rights laws and do not discriminate or exclude people because of their race, color, religion, gender, gender identity, sex, sexual orientation, age, disability, national origin, military status, veteran status, genetic information, ancestry, ethnicity, marital status, language, health status, or need for health services.
Non-Discrimination Notice – English
Non-Discrimination Notice – Spanish
Notice of Availability of Language Assistance Services and Auxiliary Aids and Services
Humana Inc. and its subsidiaries comply with Section 1557 by providing free auxiliary aids and services to people with disabilities when auxiliary aids and services are necessary to ensure an equal opportunity to participate.
Auxiliary Aids and Services Notice – English
Auxiliary Aids and Services Notice – Spanish
Performance measurement
Refer to the below information to see how we’re measured as a health plan and also how we’re doing.
Guide to HEDIS® measurements
State of Health Care Quality Report (NCQA)
Expanded Benefits Reimbursement Form
We hope you don’t have to pay out-of-pocket for the benefits you get as a Humana Healthy Horizons in South Carolina member. If you do, let us know by filling out a reimbursement claim form, and you may get a refund.
Fill out the form below to send a reimbursement claim.
Expanded Benefits Reimbursement Form – English
Expanded Benefits Reimbursement Form – Spanish
Pharmacy
Over-the-Counter Catalog and Order Form
As a Humana Healthy Horizons in South Carolina member, you can use Humana’s mail-order pharmacy, CenterWell Pharmacy®, which will send medicine to your home.
Your pharmacy benefit lets you order certain over-the-counter (OTC) items through the mail. To get started:
- Look up available OTC items in the Humana Health and Wellness Catalog
- Write down your order on the Order Form
- Submit your order:
- By mail:
CenterWell Pharmacy
P.O. Box 745099
Cincinnati, OH, 45274-5099
- By phone: Call 800-379-0092 (TTY: 711), Monday – Friday, 8 a.m. – 11 p.m., and Saturday, 8 a.m. – 6:30 p.m., Eastern time.
- By mail:
Humana Health and Wellness Catalog and Order Form – English
Humana Health and Wellness Catalog and Order Form – Spanish
Prescription Drug Reimbursement Claim Form
We hope you don’t have to pay for any medicine out of pocket. If it happens, please fill out the form below to send in a reimbursement claim if you paid out of pocket for a prescription. We will try to pay you back.
Prescription Drug Reimbursement Claim Form
Humana Healthy Horizons in South Carolina
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Contact Us
If you have questions, find the number you need to get help and support.
Find Care
Find a doctor, hospital, or pharmacy.
Documents & forms
Find the documents & forms you need, including your Member Handbook.