Fillable Form 14423-Standard-0814 - Prescription Reimbursement Claim Form

Form 14423-Standard-0814 - Prescription Reimbursement Claim Form - Caremark

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14423-STANDARD-0814

Prescription Reimbursement Claim Form

Important!

Always allow up to 30 days from the time you receive the response to allow for mail time plus claims processing.

Keep a copy of all documents submitted for your records.

Do not staple or tape receipts or attachments to this form.

Reimbursement is not guaranteed and other contractor will review the claims subject to limitations, exclusions

and provisions of the plan.

STEP 1

Card Holder/Patient Information

This section must be fully completed to ensure proper reimbursement of your claim.

Card Holder Information

Identification Number (refer to your prescription card)

Group No./Group Name

Name (Last Name)

(First Name)

(MI)

Address

Address 2

City

State

Zip

Country

Patient Information–Use a separate claim form for each patient.

Name (Last Name)

(First Name)

(MI)

Date of Birth

Male

Female

Phone Number

Relationship to Primary member

Spouse

Other_______________

Member

Child

Other Insurance Information

COB (Coordination of Benefits)

Are any of these medicines being taken for an on-the-job injury?

Yes

Is the medicine covered under any other group insurance?

Yes

If yes, is other coverage:

Primary

Secondary

If other coverage is Primary, include the explanation of benefits (EOB) with this form.

Name of Insurance Company____________________________ ID#________________________

Important! A signature is REQUIRED

NOTICE

Any person who knowingly and with intent to defraud, injure, or deceive any insurance company, submits a claim or application containing any

materially false, deceptive, incomplete or misleading information pertaining to such claim may be committing a fraudulent insurance act which is a

crime and may subject such person to criminal or civil penalties, including fines, denial of benefits, and/or imprisonment.

I certify that I (or my eligible dependent) have received the medicine described herein. I certify that I have read and understood this form, and that all

the information entered on this form is true and correct.

Date

Signature of Plan Participant

(Over)