Prime Therapeutics requires that a check be outstanding for two weeks before a check inquiry is submitted.

To submit a check inquiry, please complete the form below. A replacement check will be issued to you in 2 to 3 weeks, provided that the original check has not been cashed.

Note that fields with a * must be completed.

1. Issue Date (Approximate) *
2. Amount (Approximate) *
3. Check Number (If Known)
4. Health Plan * -- Select a Health Plan from List -- HCSC (Includes IL, NM, TX) Blue Cross and Blue Shield Florida Blue Cross and Blue Shield Kansas Blue Cross and Blue Shield Minnesota Blue Cross and Blue Shield Nebraska Blue Cross and Blue Shield North Dakota Blue Cross and Blue Shield Wyoming Other (specify below)
5. specify "other" health plan

1. Member Name *
2. ID/Contract # *
3. Address *
4. City, State, Zip *
5. Is this a new Address? Yes     No

1. Comments