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)