Medicare Part D Prescription Claim Form
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1
2Medicare Part D
Prescription Claim Form
Part 1
Plan Participant ID No.
Plan Participant Name
Plan
Address
Participant
Information
City
State
ZIP
Phone (
)
Plan Participant Information — Please use a separate claim form for each cardholder
Please complete
Plan Participant Name
Date of Birth
Part 1 fully to
ensure proper
Plan Participant:
q Male
q Female
reimbursement
COORDINATION OF BENEFITS (COB)
of your claim.
Is the medicine covered under any other group insurance?
q Yes
q No
If yes, is the other coverage: q Primary q Secondary
Please type or
If the other coverage is primary, include the explanation of benefits (EOB) with this form when you return this form.
print clearly.
Name of Insurance Company
ID #
Important! A signature IS REQUIRED in both A and B.
Fraud Prevention Regulation: Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance or statement of claim containing any materially false information
or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime and subjects such person to criminal and civil penalties.
A
×
Signature of Plan Participant
Date
Release of Information: I certify that I have received the medicine described herein and that I am the plan
participant named and am eligible for prescription benefits. I also certify that the medicine received is not for
treatment of an on-the-job injury or covered under another benefit plan. I authorize release of all information
pertaining to this claim to FutureScripts Secure, the prescription benefit manager; insurance underwriter;
sponsor; policyholder; and/or employer. I certify that all the information entered on this form is correct.
B
×
Signature of Plan Participant
Date
Part 2
If you are including original receipts that contain the information below, STOP HERE and submit the claim.
It is not necessary to complete Part 3. NOTE: Please enclose but do not staple or tape receipts or attachments
Remember to
to this form.
include original
• Plan participant name
• Pharmacy name and address or NABP number
• Prescription number
pharmacy receipts.
• Date purchased
• Total charge
• Medicine strength/or
Keep copies for
• Medicine name
• Metric quantity, day, supply
NDC number
your records.
Part 3
• To ensure that the plan participant receives accurate and timely reimbursement for medicine purchases,
please assist in completing the information below.
Pharmacy
• If this is a compound prescription, please enter COMPOUND RX in the space designated for the NDC # and
Information
complete the Compound Prescriptions section on the reverse side.
Pharmacist to
Pharmacy name
Pharmacy NABP No.
complete this
Pharmacy address
section ONLY if
original pharmacy
City
State
ZIP
Phone (
)
receipts are not
I hereby certify that all the information listed below is correct and represents the actual charge(s) for
enclosed with this
prescription(s) dispensed. I further understand that all benefit payments as related to the charges listed
form.
below will be paid directly to the plan participant.
×
Signature of Pharmacist or Representative
Date
(Required only if original pharmacy receipts are not included)
For office use only
q Compound
Rx #
Date Filled (mm/dd/yy)
Prescriber’s DEA No.
Prior Approval Code
NDC #
Medicine Name and Strength
Metric Quantity Days Supply
Total Charges
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