Claim

PDF  Claim Form - Medical (FEP)

Federal Employee Program (FEP) members use this form to file a medical claim. ID: 10407

PDF  Claim Form - Medical - Reimbursement - Orally Administered Cancer Medication Coverage

Use this form to request reimbursement for cancer medication. ID: 5337

PDF  Dental - Patient Encounter Form

This is a Dental claim form used by the dental provider for patient encounters. ID: 2954

PDF  Prescription Drug 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