Form Gc-1564 - Commercial Prescription Drug Claim Form - 2012
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1
2Commercial
Aetna Pharmacy Management
PO BOX 52444
Phoenix, AZ 85072-2444
Prescription Drug Claim Form
Fax Number: 1-888-472-1128
Aetna Member Number (claim cannot be processed without number)
Group Number
If you are enrolled in Medicare, check here
Student Name (First, Middle, Last)
Student Birthdate (MM/DD/YYYY)
Student Address (Street, City, State, ZIP Code)
School Name & Address (Street, City, State, ZIP Code)
Student Signature
Student Telephone Number
Date
(
)
Prescription(s) were for:
Student
Spouse
Dependent
Last Name, First, Middle Initial
Gender
Patient Birthdate (MM/DD/YYYY)
Male
Female
Are any family members expenses covered by another group health plan, group pre-payment plan (Blue Cross-Blue Shield, etc.), no fault auto insurance,
No
Yes
Medicare, or any federal, state, or local government plan?
If Yes, list policy or contract holder, policy or contract number(s) and name/address of insurance company or administrator.
If Medicare, check all that apply.
Medicare Part A
Medicare Part B
Medicare Part D
Member's Birthdate (MM/DD/YYYY)
Member's ID Number with Other Carrier
Member's Name
Indicate reason for manually filing these claims:
Coordination of Benefits – Please attach an Explanation of
Emergency – If Emergency, describe Emergency below, or on a
Benefits from the primary carrier along with the detailed receipt.
separate sheet
Please Note: Manual submission of claims does not guarantee reimbursement of claim.
Please attach detailed prescription receipts or ask your pharmacist for a pharmacy statement. We cannot
Pharmacy Information
process your claim without this information.
Member
• Please read carefully before completing this form. Claim forms without the required information cannot be
processed. Incomplete forms will be returned to you.
• If you use more than one pharmacy, use a separate form for each pharmacy.
• Use a separate claim form for each patient.
• Claims must be submitted within two years of date of purchase.
• Complete all employee and patient information on the top portion of the form and be sure to sign it.
• Mail or FAX the Prescription Drug Claim Form to: Aetna Pharmacy Management
PO BOX 52444
Phoenix, AZ 85072-2444
Fax Number: 1-888-472-1128
GC-1564 (10-12)
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Parent category: Business