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  • Highmark Form Mm-056 2013

Get Highmark Form Mm-056 2013-2025

Ur Web site at the addresses listed above. Fax each form separately. Please use a separate form for each drug. Print, type or write legibly in blue or black ink. See reverse side for additional details PATIENT INFORMATION Subscriber ID Number Highmark Coverage Group Number n MA-PD n PDP Patient Telephone Number Patient Name Patient Address Date of Birth City State Zip Code CLINICAL / MEDICATION INFORMATION Drug Name Strength or Dose Diagnosis Name of the Carrier who paid for Most Rece.

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Blue Cross NC began its partnership with Prime Therapeutics (Prime) for pharmacy benefits management on April 1, 2012.

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.

CarelonRx* is the pharmacy benefits manager. * CarelonRx, Inc. is an independent company providing pharmacy benefit management services and some utilization review services on behalf of Highmark Blue Cross Blue Shield of Western New York.

Highmark Blue Shield administers prescription benefits for almost all of its members. The Paid Prescriptions program logo appears on the member's identification card. Medco Health is our pharmacy benefits manager.

Prime Therapeutics LLC is an independent pharmacy benefit management company, contracted by Blue Cross & Blue Shield of Rhode Island (BCBSRI) to provide pharmacy benefit management services.

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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
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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:
1-877-389-0141
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