Blue Care Network Prescription Drug Claim Form

Who is this for?

Michigan Health Insurance – Customer Service – Documents and Forms

If you're a Blue Care Network member, use this form if you filled a prescription at a pharmacy that doesn't accept BCN and you'd like to get reimbursed.

Many pharmacies in Michigan are in our network. But if you need prescription medication in an emergency and can't find a participating pharmacy, you may have to pay for them yourself.

If you have an Rx logo on your enrollee ID card, you can use this form to ask us to pay you back for that expense. You'll be reimbursed based on our allowed amount less any applicable copayment.

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, please contact us.

Blue Care Network members prescription drug claim form (PDF)

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