Prescription Drug Forms
Claim Form *
(If you are submitting a claim for a prescription drug charge, use this form for any BlueRX product, except BlueRX Direct).
- PrimeMail Order Form (Use the forms on this site only if you have BlueRx Mail.)
- Prime Coverage Exception (offsite link)
Therapeutics Prescription Drug Claim Form *
Use this form to submit a claim only if you have prescription drug coverage through your employer. Otherwise, use the Member Claim Form (Form 34-4) above.
* You may fill out and print this form using your Acrobat Reader program.