Blue Access for Producers

Downloadable Forms for 51-150 Employees

Prescription Drug Forms

Form NameForm NumberDate
Prime Prescription Drug Claim Form  #3272-IL 1/16
PrimeMail Order Form  #3208-IL 04/16
Walgreens Mail Service Registration and New Prescription Order Form  (HMO only) #WI0261 03/15
HMO 90-Day Supply Mail Service ONLY – Walgreens Mail Service Physician Fax Form  #WI0261 03/15
General Notice of Special Enrollment Rights and Preexisting Condition Exclusion  #225425 09/13