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PHARMACY COVERAGE GUIDELINES SECTION: DRUGSORIGINAL EFFECTIVE DATE: LAST REVIEW DATE: LAST CRITERIA REVISION DATE: ARCHIVE DATE:5/07/15 5/17/18 5/17/18JAKAFI (ruxolitinib phosphate) oral tablet Coverage
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To fill out Blue Cross Blue form, follow these steps:
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Begin by entering your personal information, such as your name, address, date of birth, and contact details.
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Provide your insurance information, including your Blue Cross Blue Shield identification number and group number.
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Indicate the date of service and the healthcare provider's details, such as their name, address, and contact information.
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Enter the diagnosis or reason for the medical visit and the corresponding medical codes, if required.
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Fill out the details of the services received, including the procedure codes, description, and any applicable charges.
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Include any supporting documentation, such as medical reports or itemized bills, if necessary.
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Sign and date the form, certifying that the information provided is accurate and complete.
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Finally, submit the completed form to your Blue Cross Blue Shield insurance provider for processing.

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Blue Cross Blue Shield is a nationwide healthcare provider network that offers insurance plans for individuals, families, and businesses.
Employers and individuals who are enrolled in a Blue Cross Blue Shield insurance plan are required to file their claims and other necessary paperwork.
To fill out Blue Cross Blue Shield forms, individuals and employers can submit their information online through the company's website or by mail.
The purpose of Blue Cross Blue Shield is to provide access to affordable healthcare services and insurance coverage for its members.
Information such as member ID numbers, diagnosis codes, provider information, and treatment details must be reported on Blue Cross Blue Shield forms.
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