Prescription Drug Forms

Printable PDF Forms

• Member 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 Therapeutics Prescription Drug Claim Form *
  (Use this form to submit a claim only if you have BlueRx Direct.)

* You may fill out and print this form using your Acrobat Reader program.