Blue Care Network Prescription Drug Claim Form

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.

Prescription Drug Reimbursement 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

If you have any questions, please contact us.

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