Retail Prescription Drug Overseas Claim Form - Federal Employee Program Page 2
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1
2General Information
This Retail Prescription Drug Overseas Claim Form is to be used only to submit a claim for benefits for prescription
drugs purchased outside of the United States and Puerto Rico. Please complete a separate claim form for each
patient and remember to file all claims by December 31 of the calendar year after the one in which the purchase was
made.
The Retail Prescription Drug Overseas Claim Form must be completed in full and accompanied by the prescription
drug receipts/bills. ENROLLEE/PATIENT SIGNATURE REQUIRED.
Please be sure to keep photocopies of the claim form and all bills and supporting documentation for your personal
records.
Any person who knowingly and with intent to defraud any insurance company or other person files a claim for reim-
bursement containing any materially false information or conceals for the purpose of misleading commits a fraudulent
insurance act, which is a crime and subject to criminal and civil penalties.
Prescription Claim Information – Please list the prescriptions included on this claim. Although we require prescrip-
tion drug receipts, your listing will enable us to process the claim more quickly and accurately.
• Date Purchased – The date you paid for the prescription.
• Quantity – The number of tablets, capsules, or the liquid measure of the prescription.
• Days Supply – The number of days for which the prescription was written.
• Name of Medication – The name of the medication as indicated on the prescription drug receipt.
• U.S. Drug Equivalent Name – The name of the prescription drug in English.
• Form of Medication – Such as a cream, tablets, capsules, liquid, etc.
• Strength – This is the strength of medication per dose, such as 50 mg for tables or .05 ml for liquids.
• Prescription Cost – Please indicate the cost you paid in foreign currency.
THIS SIGNED AND COMPLETED CLAIM FORM, TOGETHER WITH YOUR PRESCRIPTION DRUG
RECEIPTS/BILLS SHOULD BE SUMITTED TO THE ADDRESS ON THE FRONT OF THE FORM, OR YOU CAN
FAX TO: 001-480-614-7674
DIRECT DEPOSIT TO YOUR BANK ACCOUNT IS CURRENTLY NOT AVAILABLE FOR OVERSEAS PHARMACY
CLAIMS PAYMENT. PAYMENT WILL BE MADE BY CHECK IN U.S. CURRENCY.
PLEASE USE THE FEDERAL EMPLOYEE PROGRAM OVERSEAS MEDICAL CLAIM FORM FOR ALL OTHER MEDICAL
EXPENSES INCURRED OUTSIDE THE US AND PUERTO RICO.
ADDITIONAL CLAIM FORMS OR INFORMATION ARE AVAILABLE ON OUR WEB SITE,
OR BY CALLING
1-888-999-9862
CUT0154-1S F 12/13
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