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 subscriber ID card, formerly known as enrollee ID, 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 copay.

You can still submit claims for prescription drug expenses in 2021. Please use the 2021 Blue Care Network members prescription drug claim form (PDF).

What you’ll need

  • Subscriber ID card, also known as 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

You may also request reimbursement for your prescription electronically. Follow the instructions below to submit your claim online.

  • Log in to your member account on our website
  • Click Forms
  • Click Reimbursement Form
  • Click Online Form
  • Verify your contact information 
  • Click Prescription and follow the prompts to submit your online claim

If you have any questions, please contact us.