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Pharmacy Forms

PDF  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

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. ID: WI0438-1117

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  Medicare Claim Form

Claim form for Medicare Part D prescriptions. ID: 2875

PDF  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

PDF  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