Fillable Express Scripts Claim Form printable pdf download

Health

Express Scripts - BOR

Mail Route # BOR-01

PO Box 390863

Bloomington, MN 55439-0873

Clear form

Member Services Phone Number: 1-877-650-9341

Member Reimbursement Claim Form

IMPORTANT INSTRUCTIONS

When should you use this form?

Your claim cannot be processed unless this form is complete.

♦

A separate claim form must be completed for each member/patient.

1) Between the effective date of your eligibility with your prescription

Please complete all of the information requested under Part A.

program and the receipt of your pharmacy ID card;

♦

Please complete Part B by using the information on the packaging of

2) If you are unable to use an In-Network pharmacy; or

your prescription or by using your pharmacy receipt. You may ask

If you are asked to pay for the total cost of your prescription at a

your pharmacist for assistance.

participating pharmacy.

♦

Please tape your pharmacy receipt(s) to 81/2 by 11 sheet of paper and

include it with this form.

There will be no Coordination of Benefits (COB) for allowed

♦

Please review, sign, and mail your completed form with pharmacy

pharmacy charges between the Board of Regents pharmacy

receipt(s) to the address at the top of this form. Note: PHARMACY

plan and another pharmacy/medical plan in which the

RECEIPT(S) ARE REQUIRED (legible copies are acceptable).

member may be enrolled.

[Cash register receipts are not accepted.]

Address Information

Did you (member/patient) use a

! ! ! ! Yes ! ! ! ! No

_________________________________________________

network pharmacy?

First name

M I

Last name

Member Name

_________________________________________________

Does the member/patient reside in a

! ! ! ! Yes ! ! ! ! No

Mailing Address

nursing home?

_________________________________________________

City, State, Zip Code

Does the member/patient reside in an

! ! ! ! Yes ! ! ! ! No

_________________________________________________

assisted living care facility?

Telephone Number

REQUIRED INFORMATION

Part A

Pharmacy/Physician/Member/Patient Information

Pharmacy NCPDP # ___ ___ ___ ___ ___ ___ ___

Name of Pharmacy __________________________________

)

(Please ask your pharmacist or check your pharmacy receipt

Physician Name ____________________________

Physician DEA # ___ ___ ___ ___ ___ ___ ___ ___ ___

(Please ask your physician for this number)

Member ID # ______________________________

Patient Name _______________________________________

(Please refer to the front of your ID card)

Date of Birth_____/_____/_____ Gender: M ! ! ! ! F ! ! ! !

Relationship: ! ! ! !

! ! ! !

Member

Spouse

Dependent

Part B

Prescription Information – Please contact your pharmacist if you need assistance

Date

Prescription

National Drug Code

Quantity

Days

Amount

Dispensed

Number (RX#)

(NDC# 11 Digits)

(QTY)

Supply (DS)

Paid

AUTHORIZATION

: I authorize the release of any information necessary to process this claim and I also certify that the above

information is correct

. A photocopy of this authorization shall be as valid as the original.

Member or Authorized Signature:_____________________________________________ Date: _____________________

" " " "

(Processing Center Use ONLY )

Claim Form Returned

PLEASE PROVIDE HIGHLIGHTED INFORMATION AND RESUBMIT.

" " " " Claim Form Required " " " " Send to previous processor, claim dates are prior to effective date with Express Scripts/DPS. " " " " Pharmacy Receipt(s) " " " " Pharmacy NCPDP#

" " " " Pharmacy Name " " " " Dr. DEA# " " " " Dr. Name " " " " Participant ID Number " " " " Participant Name " " " " DOB, Gender, Rel. Code " " " " Date Dispensed " " " " Prescription Number(RX)

" " " " National Drug Code(NDC) " " " " Quantity(QTY) " " " " Days Supply(DS) " " " " Amount Paid " " " " Explanation of Benefits or Pharmacy Patient Profile- Part B you have indicated

that you have primary coverage through another carrier. " " " " Coordination of Benefits (COB) is not an option under your benefit. " " " " Signature " " " " Participant not in system,

contact your health plan or employer. " " " " The NDC# for the most expensive legend ingredient is required for compound medications. " " " " Submit claim(s) to your major

medical insurance for processing. " " " " Other_______________________________________________________________________________________01/01/2001