Prescription Drug Claim Form - Bcbstx.com 2026

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The document is a Prescription Drug Claim Form that requires patients to provide personal and prescription information to claim benefits for medications. It includes sections for patient details, pharmacy information, and instructions for submitting original pharmacy receipts. The form emphasizes the importance of accurate information and compliance with HIPAA regulations, while also outlining the consequences of fraudulent claims.

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Click ‘Get Form’ to open the Prescription Drug Claim Form in our editor.
Begin by filling out the Patient Information section. Enter the patient's name, ID number, date of birth, and gender. Ensure all details are accurate for a smooth claims process.
In the Prescription Claim Information section, provide the NDC number, prescription cost, balance due, and other relevant details. If you have multiple prescriptions, repeat this step for each one.
Attach original pharmacy receipts in the designated spaces on the back of the form. If receipts are missing, have your pharmacist complete and sign where indicated.
Complete the Subscriber/Member Information section with necessary details about the insurance policy and relationship to the patient.
Review all entries for accuracy before signing at the bottom of the form. Ensure that all required fields are filled out to avoid delays in processing.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I speak to a representative at BCBSTX?

Call us toll-free at 1-888-657-6061 (TTY: 711).

How do I get a Medicare prescription claim form?

Form CMS-1696 can be downloaded at .cms.gov or obtained by calling the Customer Service number on your member ID card. The claim may be submitted via mail or fax to the address or phone number on the Medicare Part D Prescription Drug Claim Form.

What is the PBM for BCBS of Texas?

Blue Cross and Blue Shield of Texas utilizes Prime Therapeutics LLC as our pharmacy benefit manager to administer certain core services in our pharmacy program that will help contain rising drug costs and maintain and improve the quality of care delivered to members.

Does BCBS Texas use express scripts?

To send a prescription order through the mail, visit bcbstx.com and log in to Blue Access for MembersSM. Complete the mail order form. Mail your prescription, completed order form and payment to Express Scripts Pharmacy. Ask your doctor for a prescription for up to a 90-day supply of each of your long-term medicines.

Who are the PBM in Texas?

What is a pharmacy benefit manager? In its statute governing third party administrators, Texas Insurance Code Section 4151.151 defines pharmacy benefit manager as a person, other than a pharmacy or pharmacist, who acts as an administrator in connection with pharmacy benefits.

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What is the provider line for BCBS of Texas?

Provider Services Hotline If your provider needs to contact us, they may call 1-877-784-6802.

What is a prescription claim?

Prescription Claim means any electronic or paper request for payment or reimbursement arising from retail participating pharmacies, mail-order pharmacies, and specialty pharmacies, Sample 1.

Who is the PBM for BCBS of TX?

Prime Therapeutics is the PBM that provides drug benefits through BCBSTX.