To request reimbursement for out-of-pocket mail order pharmacy expenses, please complete the Pharmacy Mail Order Expense Reimbursement Form. Be sure to sign and date the completed form. 6.Mail claim form and all attachments to BCBSMA, P.O. Box 986030, Boston, MA 02298. How do I fill this out? To be reimbursed, submit a form to Blue Cross Blue Shield of Massachusetts. A request form is included with this document. File this form when you receive a bill for services for which the provider does not directly submit a claim to Blue Cross and Blue Shield of Massachusetts. Find forms for reimbursement, authorization, claims, and more. Click on the form you need and it will open in PDF format so you can print it. You can download and fill out a form, called the Patient Request for Medical Payment form (CMS-1490S).