WebImportant Legal Information: Highmark Blue Shield, Highmark Benefits Group, Highmark Choice Company, Highmark Senior Health Company, and/or Highmark Health Insurance Company provide health benefits and/or health benefit administration in the 21 counties of central Pennsylvania and 13 counties in northeast and north central Pennsylvania. WebTo order from AllianceRx Walgreens, use this form: AllianceRx Walgreens Mail Order Form (PDF) Mail the completed form to: AllianceRx Walgreens Pharmacy. P.O. Box 29061. Phoenix, AZ 85038-9061. If you have questions, call AllianceRx at: 1-866-877-2392. TTY users call 1-800-925-0178.

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WebAll commercial members, including self-insured members who have an exclusive specialty … WebSPECIALTY DRUG REQUEST FORM Once completed, please fax this form to1-866-240-8123. To view our formularies on-line, please visit our Web site at the addresses listed above. Please use a separate form for each drug. Print, type or WRITE LEGIBLY and complete form in full. If approved, the payor will forward to the exclusive specialty vendor. smart home sewa

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WebSpecialty Drug Request Form picture_as_pdf DOWNLOAD PDF Vision Claims, mail order, … WebHighmark Blue Cross Blue Shield West Virginia Specialty Drug Request Form Once completed, please fax this form to Walgreens at 1-877-231-8302. Please use a separate form for each drug. Print, type, or WRITE LEGIBLY and complete form in full. Walgreens will contact Highmark WV for authorization, if necessary. Walgreens can be reached at (888 ... WebFax each form separately. Please use a separate form for each drug. Print, type or write … hillsdale canadian small cap equity fund