• Preferred Drug List
• Prescription Reimbursement Claim Form
  • Members with pharmacy benefits through Blue Cross and Blue Shield of Texas can use this form to file pharmacy claims for reimbursement.
• Mail Order Prescription Form
  • Members with pharmacy mail order benefits through Blue Cross and Blue Shield of Texas can use this form to order prescription medication by mail.
• Quantity Limit Override Request Form
  • The Quantity Override Request Form should be completed by the prescribing physician and submitted to Pharmacy Programs when requesting an override for their patient. If they do not have this form available, we ask that they fax or e-mail the information that is requested on this form.
• Quantity Limit Overrride Request Form--Proton Pump Inhibitors
  • This Quantity Limit Override Request Form serves the same purpose as the general request form provided above except this form is used for override requests specifically for drugs classified as Proton Pump Inhibitors.

Note: If these downloadable PDF forms are altered in any way they will not be processed by Blue Cross and Blue Shield of Texas.