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Pharmacy Claims and Providers

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    What does "participating pharmacy" mean?

    "Participating pharmacy" means a pharmacy that has an agreement with Blue Shield to provide covered services to our members.
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    What happens if I use a non-participating pharmacy?

    Most drug benefits do not include coverage for non-participating pharmacies, unless the prescription is obtained in conjunction with a covered emergency. If you fill your prescription at a non-participating pharmacy, you must pay the pharmacist for the entire cost of the prescription and then submit a claim form to be reimbursed. If the claim is approved, your co-payment or co-insurance may be more than you would have paid, if you had used a participating pharmacy. Depending on the design of your benefit, you will also be responsible for any penalties, deductibles, and applicable co-payment/co-insurance. Check your Evidence of Coverage (EOC) or Certificate of Insurance (COI) for your specific copayment information.
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    I had to pay out of pocket for my medication, how do I get reimbursed?

    There are a few circumstances when you need to file a prescription drug claim:

    • If you have filled your prescription at a non-participating pharmacy, you can submit a completed claim form along with a detailed receipt. (Check your Evidence of Coverage (EOC) or Certificate of Insurance (COI) to determine if this applies to your plan). Reimbursement will be based on if the medication is covered by Blue Shield and any applicable co-payment, co-insurance percentage, co-payment penalty and/or pharmacy deductibles. You can obtain additional claim forms by contacting the Member Services phone number listed on your Blue Shield ID card.
    • If you are a new member who did not receive a Blue Shield ID card during the first 30 days of becoming a Blue Shield member and you need a prescription, you may pay the pharmacist for the entire cost of your prescription and then submit a claim form to Blue Shield to be reimbursed for any covered medication.

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    If I submit a pharmacy claim, how long does it take for a check to be sent to me?

    We will generally process your pharmacy claim within 21 business days of when it is received. If your claim is approved, you can expect a reimbursement check within 4 – 6 weeks from when we received your claim.
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