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Prescription drug reimbursement claim form
www.bcbsm.comdelay your reimbursement. Form instructions • •Complete this claim form if you paid full price for a prescription . and the pharmacy did not submit a claim to Blue Cross Blue Shield of Michigan and Blue Care Network, or if you are submitting a claim for coordination of benefits. • Complete a separate claim form for each patient and each
Prescription Drug Reimbursement Claim Form - …
www.bcbsm.comPrescription Drug Reimbursement Claim Form Be sure to complete the detailed claim information on the back of this form. Claims may be returned if incomplete. Enrollee Name: First Last