Form 14423-Standard-0814 - Prescription Reimbursement Claim Form - Caremark Page 2
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1
2STEP 2
Submission Requirements:
You MUST include all original “pharmacy” receipts in order for your claim to process. “Cash register” receipts will only be
accepted for diabetic supplies. The minimum information that must be included on your pharmacy receipts is listed below:
• Patient Name
• Prescription Number
• Medicine NDC number
• Date of Fill
• Metric Quantity
• Total Charge
• Days Supply for your prescription (you need to ask your pharmacist for this “Day Supply” information)
• Pharmacy Name and Address or Pharmacy NABP Number
A valid Prescribing Physician’s NPI (National Provider Identification) number is required, please provide: ____________
Prescribing physician’s information (all fields required):
Name: ___________________________________________________________________________
Address: __________________________________________________________________________
City, state, zip code: ________________________________ Phone number: ________________________
Additional Comments
STEP 3
Mailing Instructions:
The RXBIN # is located on front of your
Present this Prescription Card to fill your prescription at
any participating retail pharmacy.
CVS/caremark Prescription ID card. Please
For more information, visit
RxBIN
004336
RxBIN
004336
see highlighted area to the left for reference.
or call a Customer Care representative toll-free at
RxPCN
ADV
1-877-347-7444.
RxGRP
RXTEST
Match your RXBIN # to the addresses below.
Issuer (80840)
Pharmacy Help Desk for Pharmacists: 1-800-364-6331
ID
123456789
Submit paper claims to:
NAME
JOHN Q SAMPLE
CVS/caremark Claims Department
P.O. Box 52136, Phoenix, AZ 85072-2136
GLOBAL-IDCB-7444-0614
RXBIN # 610415 mail to:
CVS/caremark
P.O. Box 52116
Phoenix, Arizona 85072-2116
RXBIN # 004336 , 012114 or if you are unable to locate your bin # mail to:
CVS/caremark
P.O. Box 52136
Phoenix, Arizona 85072-2136
RXBIN # 610029 mail to:
CVS/caremark
P.O. Box 52196
Phoenix, Arizona 85072-2196
IMPORTANT REMINDER–
To avoid having to submit a paper claim form:
• Always have your card available at time of purchase.
• Always use pharmacies within your network.
• Use medication from your formulary list.
• If problems are encountered at the pharmacy, call the number on the back of your card.
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