Prescription Drug Foreign Claim Form

Who is this for?

Michigan Health Insurance – Customer Service – Documents and Forms

If you're a Blue Cross Blue Shield of Michigan member, use this form if you filled a prescription at a pharmacy while traveling outside of the country and you'd like to get reimbursed.

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

But if you're traveling in a foreign country and need a prescription filled, you may have to pay up front. You can use this form to ask us to reimburse you 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

Be sure to provide all information for each drug in English. If you have any questions, call the number on the back of your enrollee ID card, or please contact us.

Prescription drug foreign claim form (PDF)

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