Form Gc-1360 - Aetna -Prescription Drug Claim Form
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1
2Aetna
Prescription Drug Claim Form
Pharmacy Management
Attn: Claim Processing
P.O. Box 398106
Minneapolis, MN 55439-8106
Social Security Number/Member Number (claim cannot be processed without number)
Group Number
Employee Name (First, Middle, Last)
Employee Birthdate (MM/DD/YYYY)
Employee Address (Street, City, State, Zip Code)
Company Name & Address (Street, City, State, Zip Code)
Employee Signature
Telephone Number
Date
(
)
Prescription(s) were for:
Last Name, First, Middle Initial
Sex
Patient Birthdate (MM/DD/YYYY)
Employee
Spouse
Dependent
Male
Female
Indicate reason for manually filing these claims:
Coordination of Benefits
I had not received my Aetna ID card
Travel Supply
Pharmacy not participating in network
Pharmacy unable to process claim electronically
Pharmacy Information
Please attach prescription receipts or ask your pharmacist to complete the remaining information. We cannot process your
claim without this information.
1) Date Filed (MM/DD/YYYY) Rx Number
RX (Check one)
Quantity
Days Supply
National Drug Code (11 digit)
New
Refill
Medication Name, Strength & Dosage Form
Doctor Name & DEA Number
DAW (Check one)
RX Price (including tax)
________________________
Name:
0
1
2
_______________________
DEA #:
3
4
5
2) Date Filed (MM/DD/YYYY) Rx Number
RX (Check one)
Quantity
Days Supply
National Drug Code (11 digit)
New
Refill
Medication Name, Strength & Dosage Form
Doctor Name & DEA Number
DAW (Check one)
RX Price (including tax)
________________________
Name:
0
1
2
_______________________
DEA #:
3
4
5
3) Date Filed (MM/DD/YYYY) Rx Number
RX (Check one)
Quantity
Days Supply
National Drug Code (11 digit)
New
Refill
Medication Name, Strength & Dosage Form
Doctor Name & DEA Number
DAW (Check one)
RX Price (including tax)
________________________
Name:
0
1
2
_______________________
DEA #:
3
4
5
4) Date Filed (MM/DD/YYYY) Rx Number
RX (Check one)
Quantity
Days Supply
National Drug Code (11 digit)
New
Refill
Medication Name, Strength & Dosage Form
Doctor Name & DEA Number
DAW (Check one)
RX Price (including tax)
________________________
Name:
0
1
2
_______________________
DEA #:
3
4
5
Place Pharmacy Label here or enter:
Pharmacy Name
Pharmacist Signature
Date
Street Address
NABP Number
City
State
Zip Code
Pharmacy Telephone Number
(
)
GC-1360 (1-02) B-WH
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