Fillable Prescription Reimbursement Claim Form - Cvs/caremark (Page 2 of 2) in pdf

Prescription Reimbursement Claim Form - Cvs/caremark Page 2

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STEP 2

Submission Requirements:

You MUST include all original “pharmacy” receipts in order for your claim to process. “Cash register” receipts will only be

accepted for diabetic supplies. The minimum information that must be included on your pharmacy receipts is listed below:

• Patient Name

• Prescription Number

• Medicine NDC number

• Date of Fill

• Metric Quantity

• Total Charge

• Days Supply for your prescription (you need to ask your pharmacist for this “Day Supply” information)

• Pharmacy Name and Address or Pharmacy NABP Number

If the Prescribing Physician’s NPI (National Provider Identification) number is available, please provide: ____________

If this is from a foreign country, please fill in below:

Country: _________________________Currency: ___________________Amount: _________________

Additional Comments

STEP 3

Mailing Instructions:

The RXBIN # is located on front of your

Present this Prescription Card to fi ll your prescription at

any participating retail pharmacy.

CVS/caremark Prescription ID card. Please

For more information, visit

RxBIN

004336

RxBIN

004336

see highlighted area to the left for reference.

or call a Customer Care representative toll-free at

RxPCN

ADV

1-877-347-7444.

RxGRP

RXTEST

Match your RXBIN # to the addresses below.

Issuer (80840)

Pharmacy Help Desk for Pharmacists: 1-800-364-6331

123456789

Submit paper claims to:

NAME

JOHN Q SAMPLE

CVS/caremark Claims Department

P.O. Box 52136, Phoenix, AZ 85072-2136

GLOBAL-IDCB-7444-0614

RXBIN # 610415 mail to:

CVS/caremark

P.O. Box 52116

Phoenix, Arizona 85072-2116

RXBIN # 004336 , 012114 or if you are unable to locate your bin # mail to:

CVS/caremark

P.O. Box 52136

Phoenix, Arizona 85072-2136

RXBIN # 610029 mail to:

CVS/caremark

P.O. Box 52196

Phoenix, Arizona 85072-2196

RXBIN # 610474 , 610468 , 004245 or 610449 mail to:

CVS/caremark

P.O. Box 52010

Phoenix, Arizona 85072-2010

RXBIN # 610473 , 601475 mail to:

CVS/caremark

P.O. Box 53992

Phoenix, Arizona 85072-3992

IMPORTANT REMINDER–

To avoid having to submit a paper claim form:

• Always have your card available at time of purchase.

• Always use pharmacies within your network.

• Use medication from your formulary list.

• If problems are encountered at the pharmacy, call the number on the back of your card.

Prescription Reimbursement Claim Form - Cvs/caremark Page 2

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