Downloadable Forms for 2-50 Employees
Prescription Drug Forms
| Form Name | Form Number | Date |
|---|---|---|
Mail Service Prescription Drug Program Brochure  |
#20158 | 02/06 |
| PrimeMail Non-HMO and HMO 90-Day Supply – Mail Service Order Form |
11/10 | |
| PrimeMail Physician Fax Form |
10/09 | |
| HMO 90-Day Supply Mail Service ONLY – Walgreens Mail Service Order Form |
#21813 | 03/09 |
| HMO 90-Day Supply Mail Service ONLY – Walgreens Mail Service Physician Fax Form |
#21841 | 03/09 |
| Rx Drug Card and Fully Integrated BlueSCRIPT – Claim Form |
#20157 | 07/09 |
| BlueSCRIPT Electronic Claim Service – Claim Form |
#01103 | 12/06 |
| General Notice of Special Enrollment Rights and Preexisting Condition Exclusion |
#22963 | 09/11 |
