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
