Form C2001 - Coordination Of Benefits Form (Page 2 of 2) in pdf

Claim Receipts

Please tape your receipts here. Do not staple! If you have additional receipts, tape them on a separate piece of paper.

Tape receipt for prescription 2 here.

Tape receipt for prescription 1 here.

Receipts must contain the

following information:

• Date prescription filled

• Name and address of pharmacy

• Doctor name or ID number

• NDC number (drug number)

• Name of drug and strength

• Quantity and days’ supply

• Prescription number (Rx number)

• DAW (Dispense As Written)

• Amount paid

PHARMACY INFORMATION (For Compound Prescriptions ONLY)

Date

Days

• List the VALID 11 digit NDC number for

RX#

EACH ingredient used for the compound

Filled

Supply

prescription.

• For each NDC number, indicate the “metric

VALID 11 digit NDC#

Quantity

quantity” expressed in the number of

tablets, grams, milliliters, creams, ointments,

injectables, etc.

• Indicate the TOTAL charge (dollar amount)

paid by the patient.

• Receipt(s) must be attached to claim form.

Total Quantity

Total Charge

When To Use This Form

Instructions

• You must complete a separate claim form for each pharmacy used and for each patient.

Read carefully before completing

this form

• You must submit claims within 1 year of date of purchase or as required by your plan.

1. Be sure your receipts are complete. In

Another Health Plan Paid

order for your request to be processed, all

You must first submit the claim to the primary insurance carrier. Once the Statement from the

receipts must contain the information

Primary Plan is received from the primary carrier, complete this form, tape the original

listed above. Your pharmacist can provide

prescription receipts in the spaces provided above, and attach the Statement from the Primary

the necessary information if your claim or bill

Plan, which clearly indicates the cost of the prescription and what was paid by the primary plan.

is not itemized.

Prescription Drug Programs or HMO Plans

2. The plan member should read the

Retail Pharmacies: If the primary plan is one in which a co-payment or coinsurance is paid at

acknowledgment carefully, then sign and

the pharmacy, then no EOB is needed. Just complete this form and attach the prescription

date this form.

receipt(s) that shows the co-payment or coinsurance amount paid at the pharmacy. The

3. Return the completed form

receipt(s) will serve as the EOB.

and receipt(s) to:

Medco By Mail/mail-order pharmacy: If the primary plan is Medco By Mail, complete this

Medco Health Solutions, Inc.

form and attach either the prescription receipt(s) that shows the co-payment or coinsurance

P.O. Box 14711

amount paid to the mail-order pharmacy, or the statement of benefits you receive from the

Lexington, KY 40512

mail-order pharmacy.

* California: For your protection California law requires the following to appear on this form: Any person who

knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to

fines and confinement in state prison.

* Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person, files

an application for insurance or statement of claim containing any materially false information or conceals for the

purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which

is a crime and subjects such person to criminal and civil penalties.

Visit us online anytime at

Form# C2001

11-05

Form C2001 - Coordination Of Benefits Form Page 2

Related Articles

Related forms

Related Categories