Pharmacy Forms

 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

 Mail Service Pharmacy Registration & Order Form (Spanish) – PrimeMail by Walgreens Mail Service

Use este formulario para inscribirse/remitir su primera orden de receta. ID: W0321SP-1017

 Mail Service Registration & Prescription Order Form – PrimeMail by Walgreens Mail Service

Use this form to register or submit your first prescription order. ID: W0319-0817

 Medicare Claim Form

Claim form for Medicare Part D prescriptions.

 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