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Pharmacy Forms

PDF  Enrollment Form – Horizon Medicare Blue Group Rx (PDP)

ID: HORAP094

PDF  Mail Service Pharmacy Registration & Order Form (Spanish) – AllianceRx Walgreens Prime by Walgreens Mail Service

Use este formulario para inscribirse/remitir su primera orden de receta.

PDF  Mail Service Registration & Prescription Order Form – AllianceRx Walgreens Prime by Walgreens Mail Service

Use this form to register or submit your first prescription order. ID: W0319-1118

PDF  Prescription Drug Claim Form - Prime Therapeutics

Use this claim form for prescriptions filled by Prime Therapeutics. Prime Therapeutics LLC is an independent company providing pharmacy benefit management services for Horizon BCBSNJ members. ID: 3272

Applicable Products:
Commercial PPO/EPO &
Exchange POS/EPO

Applicable Products:
Commercial HMO & POS