Pharmacy Forms
Claim Form - Prime Therapeutics
For commercial, non-Medicare members. Use this claim form for reimbursement from Prime Therapeutics for covered prescriptions. Prime Therapeutics LLC is an independent company providing pharmacy benefit management services for Horizon BCBSNJ members. ID: 3272
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.
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
Medicare Claim Form
Claim form for Medicare Part D prescriptions. ID: 2875
Request Form - Determination of Medicare Prescription Drug Coverage
Members who want exceptions to the Medicare prescription formulary and/or to copay tiering can use this form to request a Medicare prescription drug coverage determination. ID: H3154
Request Form - Redetermination of Medicare Prescription Drug Denial
Members who want exceptions to the Medicare prescription formulary and/or to copay tiering can use this form to request a Medicare prescription drug coverage determination. ID: H3154
