Blue Shield of California
50 Beale Street, San Francisco, CA 94105
Prescription Drug Reimbursement Form Information and Instructions
1. If you are a Medicare Part D subscriber, do not complete this form. Instead, visit our website:
https://blueshieldca.com/medicare, select plans with drug coverage then select exceptions and appeals to
download a “Coverage Determination Form,” OR contact your member service number, which is located
on your ID card.
2. To avoid undue delay, complete all required areas of information on the claim form.
3. Be sure to include your subscriber identification number (ID#) exactly as it appears on the Blue Shield
identification card. If this is not done, the reimbursement form will be returned to you.
4. Keep a copy of your receipt(s) for your records.
Instructions - How to complete this form
1. Copy the Subscriber Identification
Number on the Blue Shield ID card.
2. Subscriber name, address, and
3. Patient Name: Person for whom the
drug was prescribed.
4. Patient Date of Birth: Month, Day,
5. Patient Sex: Check Male or Female.
6. Status: Patient’s relationship to
subscriber. If other, please write in
type of relationship.
7. Please use separate claim form for each
1. Pharmacy name, address, and telephone number where the
prescription(s) were purchased.
2. Pharmacy ID (NCPDP/NPI): Obtain this number from the
pharmacy where prescriptions were purchased.
3. Tape a copy of pharmacy label receipts (not the register receipt for
payment) to the form in the space provided. The receipts must
indicate date of service, Rx number, NDC number, quantity, days
supply and the amount paid. For foreign claims, state the currency
4. For medications compounded by the pharmacy, the pharmacist must
complete and sign the sections titled, “medications compounded
by pharmacy” and “compounded medications” on page one of
5. Use a separate claim form for each pharmacy from which you
have purchased prescriptions.
Note: Claim submission is not a guarantee of payment.
Reason for Claim Submission:
Your Blue Shield ID Card was missing when you purchased your
You did not use a pharmacy in the Blue Shield Pharmacy Network.
Prior Authorization was approved after you purchased your
The pharmacy was unable to process your prescription online due
to system unavailability.
Your medication was compounded especially for you by your
You obtained more medications than your plan covers because
you required a vacation supply.
Other Reason: ___________________________________________
c/o Pharmacy Services
PO BOX 7168
San Francisco, CA 94120-7168
Include your prescription receipt with the name of the drug(s) and
state the foreign currency used.
Blue Shield of California
Attn: Foreign Claims
PO BOX 272550
Chico, CA 95927-2550