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Find the forms you need for prescriptions drug form claims, and more.
Coverage Exception Request for Individual Exchange Plan Members
Used to submit coverage exception request for drugs not covered and only applies to individual Exchange members.
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Responsible Quantity Limit Authorization Form
Provided to members for their providers to complete and submit for prior authorization.Applies to members with Prescription Benefits that require prior authorization or prior coverage.
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Responsible Steps Authorization Form
Provided to members for their providers to complete and submit for prior authorization. Applies to members with Prescription Benefits that require prior authorization or prior coverage.
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Prior Authorization Form
Provided to members for their providers to complete and submit for prior authorization. Applies to members with Prescription Benefits that require prior authorization or prior coverage.
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Prescription Drug Claim
Used to submit a prescription drug claim directly to Florida Blue.
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Prescription Fax Form for Home Delivery
Provided to members for their providers to submit prescriptions by fax
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Pharmacy Mail Form for Home Delivery
Used to submit prescriptions by mail.
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FB MEM TLS 001 NF 062018
