Prescription drug forms

Printable PDF Forms 

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.