Medicare Part D Prescription Claim Form Page 2

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INSTRUCTIONS
To avoid delays in handling your claim, please be sure all information is complete and correct.
A separate claim form must be completed for:
• Each plan participant/family member
• Each pharmacy from which you purchase prescription medicines
Obtain additional claim forms from your company or association and mail directly to the FutureScripts Secure Claims Department.
CLAIMS SUBMISSION
When submitting a claim, the following information must be included on enclosed receipt(s):
• Date purchased
• Prescription number
• Medicine name
• Medicine strength/or NDC number
• Pharmacy name and address or NABP number
• Original pharmacy receipts
• Total charge
• Pharmacist’s signature (only if original pharmacy receipts are
• Metric quantity, days, supply
not included)
DO NOT include charges for durable medical equipment that required a prescription to obtain. No benefits will be provided under this
plan for such items.
DO NOT submit canceled checks, cash register slips or personal itemization. These are not acceptable as substitutes for original receipts.
DO NOT submit statements with “balance” amounts only.
HOW TO COMPLETE THIS FORM
Complete all plan participant information in Part 1 on reverse side.
• The Plan Participant ID number can be found on your ID card.
• Sign and date the prescription claim form in the spaces provided. Your signature certifies that the information is correct and complete.
• Please make a copy of all documents and receipts before you send them to FutureScripts Secure. No documents will be returned.
PHARMACY INFORMATION — Needed ONLY if you do not submit original receipts
Pharmacist to complete Part 3 if no original receipts submitted.
COMPOUND PRESCRIPTIONS
• Indicate pharmacy name, NABP number, address and phone number.
For pharmacy use only
• Include prescription number(s), medicine name(s), strength(s) and date filled.
Prescription
• Indicate prescriber’s DEA number and whether the prescription is a compound.
NDC #
Ingredient
Quantity
Charge
• Include NDC number(s) for the medicine(s) dispensed.
• If a compound prescription, enter the NDC number of the most expensive
ingredient of the legend medicine used.
• Indicate the medicine ingredient(s) and quantity.
• Indicate the “metric quantity” expressed in number of tablets, grams or mls
for liquids, creams, ointments and injectables.
• Indicate the “days supply” (the number of days the medicine will last).
• Indicate the amount paid by the plan participant.
• Sign and date the form.
• Pharmacist questions? Call FutureScripts Secure toll-free at 1-888-678-7015.
MAIL THIS FORM TO:
Medicare Part D Paper Claims, P.O. Box 419019, Kansas City, MO 64141
If you have questions, please contact: FutureScripts Secure toll-free at 1-888-678-7015, seven days a week, 8 a.m. – 8 p.m.
FSS1940 (10/06)
2 of 2
11007 (2006-0239) 11/06

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