Blue Shield of California prescription drug reimbursement form
Use the appropriate Direct Member Reimbursement (DMR) form below to submit a claim to be reimbursed for a prescription you paid out of pocket for at a non-participating pharmacy. For more information visit the Drug benefits and claims FAQs.
Medicare DMR form, English (PDF, 173 KB)
Medicare DMR form, Spanish (PDF, 440 KB)
Commercial DMR form, English (PDF, 278 KB)
Commercial DMR form, Spanish (PDF, 1.5 MB)
CVS Caremark mail service pharmacy order form
Learn how to get your maintenance medication through CVS Caremark, by visiting the mail service pharmacy page.
Mail service order form, English (PDF, 1 MB)
Mail service order form, Spanish (PDF, 1.1 MB)
Y0118_24_623A_C 09202024
H2819_24_623A_C Accepted 09302024
Page last updated: 10/01/2024
This information is not a complete description of benefits.
1 Specialty medications and opioids are limited to a 30-day supply.
The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
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California Physician’s Service DBA Blue Shield of California is an independent member of the Blue Shield Association.
For Blue Shield Medicare Advantage Plans: Blue Shield of California is an HMO, HMO D-SNP, PPO and a PDP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Blue Shield of California depends on contract renewal.
The company complies with applicable state laws and federal civil rights laws and does not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, ethnic group identification, medical condition, genetic information, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, mental disability, or physical disability. La compañía cumple con las leyes de derechos civiles federales y estatales aplicables, y no discrimina, ni excluye ni trata de manera diferente a las personas por su raza, color, país de origen, identificación con determinado grupo étnico, condición médica, información genética, ascendencia, religión, sexo, estado civil, género, identidad de género, orientación sexual, edad, ni discapacidad física ni mental. 本公司遵守適用的州法律和聯邦民權法律，並且不會以種族、膚色、原國籍、族群認同、醫療狀況、遺傳資訊、血統、宗教、性別、婚姻狀況、性別認同、性取向、年齡、精神殘疾或身體殘疾而進行歧視、排斥或區別對待他人。
Blue Shield of California 601 12th Street, Oakland, CA 94607
