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, 593 KB)
Medicare DMR form, Spanish (PDF, 234 KB)
Commercial DMR form, English (PDF, 144 KB)
Commercial DMR form, Spanish (PDF, 191 KB)
Y0118_24_623A1_C 12232024
H2819_24_623A1_C Accepted 01012025
Page last updated: 1/01/2025
This information is not a complete description of benefits.
1 Specialty medications and opioids are limited to a 30-day supply.
The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
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California Physician’s Service DBA Blue Shield of California is an independent member of the Blue Shield Association.
For Blue Shield Medicare Advantage Plans: Blue Shield of California is an HMO, HMO D-SNP, PPO and a PDP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Blue Shield of California depends on contract renewal.
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