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PRESCRIPTION DRUG MEDICATION REQUEST FORM FAX TO 1-412-544-7546 Please use separate form for each drug. Print, type or WRITE LEGIBLY and complete the form in full. See reverse side for additional.

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Return the completed Claim Form to: Highmark Blue Cross Blue Shield, the Claims Administrator for the medical component of the Plan, at the following address: Highmark Blue Cross Blue Shield P. O. Box 1210 Pittsburgh, PA 15230-1210 • Attach: all original itemized bills to the claim form.

In addition, you or your representative have the right to give additional information in person at the time of the appeal hearing, in writing, by phone, or by fax to 1-833-841-8074.

You should send your written grievance to: Medicare Prescription Drug Appeals Department PO Box 535047 Pittsburgh, PA 15253-5047 or Fax your request to: Medicare Appeals Department 412-544-1513 Whether you file your grievance orally or in writing, will respond to your complaint within 30 days or as quickly as the case ...

Customer Service LocationPhone NumberDaysPittsburgh Service Center 120 Fifth Avenue Place Pittsburgh, PA 15222800-816-5527Monday - FridayJohnstown Service Center 1 Pasquerilla Plaza Johnstown, PA 15901800-816-5527Monday - FridayErie Service Center 717 State Street Erie, PA 16501800-816-5527Monday - Friday

Providers in need of assistance should contact provider services at 800-241-5704 (toll-free).

Have questions about benefits or claims? Or need support in your language? Please call the number on the back of your member ID card. We provide free accommodations for those with disabilities.For help call 1-800-982-8772 and give the operator the number on the back of your member ID card.

Providers in need of assistance should contact provider services at 800-241-5704 (toll-free).

1-800-236-8641 • In the Northeastern PA Region: Fax written requests to 570-200-6880.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232