Mail Order Drug Forms

Who is this for?


If you have Medicare Part D prescription drug coverage through Blue Cross, use these forms to get your medications through the mail.

You can save time and money by ordering your Medicare prescription drugs through the mail.

Our plans offer a three-month supply of mail-order drugs from Tiers 1-4 and a one-month supply of specialty drugs from Tier 5.

You can use Optum Rx® and Walgreens mail-order pharmacies. It takes about five days for us to fill your order and get it out to you.

What you'll need

  • Your Blue Cross ID card
  • The signed prescriptions from your doctor
  • Your doctor's name and phone number
  • A check, money order or credit card

Helpful tips

  • Are you ordering for the first time? Please use the forms on this page. These versions aren't on the pharmacies' websites.
  • Need a refill? We prefer online or phone orders for refills. 
  • Your doctor can fax your prescription directly to the mail-order pharmacy.

Optum Rx®

To order from Optum Home Delivery, use this form:

Mail the completed form and your prescriptions to:

Optum Rx
P.O. Box 2975
Mission, KS 66201

If you have questions, call Optum at:
TTY users call 711
24 hours a day, seven days a week

AllianceRx Walgreens

To order from AllianceRx Walgreens, use this form:

Mail the completed form to:
AllianceRx Walgreens Pharmacy
P.O. Box 29061
Phoenix, AZ 85038-9061

If you have questions, call AllianceRx at:
TTY users call 1-800-925-0178
24 hours a day, seven days a week