Prescription Claim Form [pdf, 882 KB] Prescription Mail Service Order Form [pdf, 1155 KB] If your policy has a mail-order drug benefit, use this form to order new and/or refill mail service prescriptions.Prior Authorization Form for Prescription Drugs [pdf, 125 KB]
2016 Standard Formulary [pdf, 1152 KB] 2016 Maintenance Drug List [pdf, 313 KB] 2016 Metallic Formulary [pdf, 4923 KB] 2016 Standard with Step Therapy Formulary (Formerly known as Value Formulary) [pdf, 1191 KB] Prior Authorization List [pdf, 50 KB] Medications that require prior approval. For authorization, call 1-877-433-2973.2016 Standard/ Standard with Step Therapy Formulary Non-Covered Medications with Covered Alternatives [pdf, 348 KB]
Arkansas Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association and is licensed to offer health plans in all 75 counties of Arkansas.
Copyright © 2001-2016 Arkansas Blue Cross and Blue Shield