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Prescription drug claim form

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Healthcare benefit programs issued or administered by Capital Blue Cross and/or its subsidiaries, Capital Advantage Insurance Company^®, Capital Advantage Assurance Company^® and Keystone Health Plan^® Central. Independent licensees of the Blue Cross Blue Shield Association serving 21 counties in Central Pennsylvania and the Lehigh Valley. Communications issued by Capital Blue Cross in its capacity as administrator of programs and provider relations for all companies.

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