Prescription drug forms
Printable PDF Forms
- Member Claim Form * (to include prescription drugs processed by BCBSKS)
Use this form to submit a claim for a prescription drug charge for any BlueRx product, excluding BlueRx Direct.
- Home Delivery Order Form (Mail Order Form) (offsite link)
If you have BlueRx Mail, you can download a mail order form on this site or on express-scripts.com (offsite link).
- Prime Coverage Exception (offsite link)
- Prime Coverage Exception fax form (offsite link)
- Prime Therapeutics Prescription Drug Claim Form *
Use this form to submit a claim for a prescription drug charge if you have BlueRx Direct.
* You may fill out and print this form using your Acrobat Reader program.
You will be reimbursed for covered services.
What should I do with my claims if I go to a provider in another state?
If you receive services in another state, you will need to know if the provider is participating with the Blue Cross and Blue Shield Plan in that state. If so, the provider will need to submit the claims directly to that state's Blue Cross and Blue Shield Plan. If not, you may submit the claims to us for processing. Be sure to indicate on the claim that the provider does not participate with their state's Blue Cross and Blue Shield Plan.