Prescription Reimbursement Claim Form Page 2
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1
2HOW TO COMPLETE THIS FORM
Cardholder
Complete all cardholder and member information in Part 1 on the reverse side.
• The Cardholder ID number can be found on your ID Card.
/ Member
• Sign and Date in the space provided. Your signature certifies that the information is correct and complete.
Information
• Please make a copy of all documents and receipts before you mail. No documents will be returned.
CLAIM SUBMISSION
To avoid delays in handling your claim, be sure all information is complete and correct.
A separate claim form must be completed for:
• Each member
• Each pharmacy from which you purchase
File as soon as possible after the date of service.
Your claim must be filed by the timely filing deadline. Please refer to your coverage document for the specific
timely filing guideline.
DO NOT include charges for durable medical equipment that required a prescription to obtain. Please submit
durable medical equipment on the Member Claim Form.
DO NOT submit cancelled checks, cash register slips or personal itemization. These are not acceptable as
substitutes for original receipts.
DO NOT submit statements with “balance” amounts only.
PHARMACY INFORMATION
If a compound prescription, enter the NDC number of the most expensive ingredient of the legend medicine use.
C O M P O U N D
P R E S C R I P T I O N S
For pharmacy use only
NDC #
Prescription Ingredient
Quantity
Charge
MAIL THIS FORM TO:
CVS/Caremark
Claims
PO Box 52136
Phoenix, AZ 85072-2136
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Parent category: Business