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 Order Form (Spanish) - Prime Therapeutics

Use este formulario para pedido de medicamento recetado por correo. ID: 3208S

 Mail Order Form - Prime Therapeutics

Use this form to order new or refill prescriptions delivered by mail from Prime Therapeutics. ID: 3208

 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