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 6 and a one-month supply of specialty drugs from Tier 5.

You can use Express Scripts® 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

What to do

  1. Find the form you'll need below. Make sure you fill out the right form for your plan. There are separate forms for PPO, HMO, Prescription Blue℠ PDP and group plans.
  2. Attach your prescriptions.
  3. Include a check, money order or credit card information for payment.
  4. Mail the form to the address listed below.

Helpful tips

  • Are you ordering for the first time? Please use the forms below. 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.

If you bought your own insurance, use these mail-order forms:

If you get your insurance through an employer, use these mail-order forms: