Mail Order Drug Forms

Who is this for?

Michigan Health Insurance – Customer Service – Documents and Forms

If you have prescription drug coverage through Blue Cross Blue Shield of Michigan or Blue Care Network, use these forms to have your medications delivered to your home.

Prescription drugs

As a Blue Cross or BCN member with pharmacy benefits, you can get prescription medications delivered to your home using the Optum Home Delivery mail order service.

Use the Optum prescription drug mail order form to get your prescription drugs by mail.

What you’ll need

  • Enrollee ID card
  • A prescription from your doctor
  • 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 member ID card, or please contact us.

Medicare member?

You can find mail order drug forms on our Medicare website.

Specialty drugs

Blue Cross and BCN members can get their specialty drugs through AllianceRx Walgreens Pharmacy. For more information, call 1-866-515-1355 or visit For a current list of specialty drugs in this program, see the Specialty Drug Program Rx Benefit Member Guide (PDF).