Prescription Drug Forms
Claim Form *
Use this form to submit a claim for a prescription drug charge for any BlueRx product, excluding 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 for a prescription drug charge if you have BlueRx Direct.
* You may fill out and print this form using your Acrobat Reader program.