BCBSMAN Prescription Drug Claim Form

When you're getting a prescription filled, the pharmacy usually just bills us electronically.

However, sometimes you may have to pay up front for prescription drugs that are covered by your insurance. If the Rx group on your Blue Cross Blue Shield of Michigan enrollee ID card is BCBSMAN, you can use this form to ask us to pay you back for that expense.

What you’ll need

• Enrollee ID card
• Pharmacy receipts
• A copier or scanner to make copies of receipts for you to keep
• A printer to print the form
• An envelope and postage to mail the form

If you have any questions, call the number on the back of your enrollee ID card, or please contact us.

Rx group number BCBSMAN reimbursement form (PDF)

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• Claim forms