Prescription Drug Claim Form

Prescription Drug Claim Form

E E a a c c h h P P h h a a r r m m a a c c y y R R e e c c e e i i p p t t M M u u s s t t S S h h o o w w : :

• Participant Name

• Drug Name/Strength or NDC Number

• Doctor’s Name or DEA Number

• Prescription Number

• Metric Quantity/Days Supply

• Purchase Date

• Pharmacy Name and Address or NABP

• Dispense as written (DAW), if

• Total Charge

Number

applicable

The submission of this claim form, for you or any of your dependents, authorizes the release of all information to applicable health care providers and all others

involved in filling the prescriptions or processing the claims submitted.

PLEASE COMPLETE SECTIONS 1 THROUGH 4. INCLUDE RECEIPTS BEFORE MAILING.

1 1

2 2

SUBSCRIBER INFORMATION

PARTICIPANT INFORMATION

Primary Participant ID# (required)

(Use a separate claim form for each covered member of the family)

Participant’s Last Name

Company Employee Number (if appropriate)

Participant’s First Name

Middle Initial

Gender:

Male

Female

Plan Sponsor

Participant’s Birthdate

Month Day

Year

Number of Receipts submitted: ______

Last Name

Participant’s Relationship to Card Holder:

Self

Spouse

Daughter

Son

First Name

Middle Initial

Widowed

Full-time Student

Sponsored Dependent/Other

Was this prescription obtained while traveling/residing outside the United

Mailing Address – Street

Apt.

Yes

No

States? Check one:

C C O O B B ( ( C C o o o o r r d d i i n n a a t t i i o o n n o o f f B B e e n n e e f f i i t t s s ) )

City

State

Zip Code

Is the medicine covered under any other group insurance?

Yes

No

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#

3 3

Reason for claim submission or special notes: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

4 4

IMPORTANT! A SIGNATURE IS REQUIRED IN BOTH A AND B

FRAUD PREVENTION REGULATION:

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.

A.

Signature of Plan Participant

Date

RELEASE OF INFORMATION:

I certify that I (or my eligible dependent) have received the medicine described herein and

that the plan participant named is eligible for prescription benefits. I also certify that the medicine received is not for

treatment of an on-the-job injury. I have indicated in the COB box above if there is primary prescription drug coverage under

another medical plan. I authorize release of all information pertaining to this claim to Caremark, the prescription benefit

manager; insurance underwriter; sponsor; policyholder; and/or employer. I certify that all the information entered on this

form is correct.

B.

Signature of Plan Participant

Date

PLEASE MAIL THIS FORM AND ALL ORIGINAL PRESCRIPTION RECEIPTS TO:

CAREMARK INC.

ATTN: CLAIMS DEPARTMENT

P.O. BOX 686005

SAN ANTONIO, TX 78268-6005

WEB CLAIM-CCF01-0406