Downloadable Forms for 2-50 Employees
Prescription Drug Forms
| Form Name | Form Number | Date |
|---|---|---|
PrimeMail New Prescription Order Form  |
#3208-IL NEW | 12/10 |
| PrimeMail Refill Prescription Order Form |
#3208-IL REFILL | 12/10 |
| PrimeMail Physician Fax Form |
10/09 | |
| Walgreens Mail Service Registration and New Prescription Order Form (HMO only) |
#21813.0309 | 03/09 |
| HMO 90-Day Supply Mail Service ONLY – Walgreens Mail Service Physician Fax Form |
#21841 | 03/09 |
| Prescription Drug Claim Form |
#3272-IL | 1/12 |
| BlueScript Program Medical Claim Form |
#01103.1209 | 12/09 |
| General Notice of Special Enrollment Rights and Preexisting Condition Exclusion |
#22963 | 09/11 |
