Form Gc-1554 - Medicare Prescription Drug Claim Form
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1
2Mail to: Aetna Pharmacy Management
Medicare
Attn: Medicare Processing
Prescription Drug Claim Form
P.O. Box 14023
Lexington, KY 40512-4023
Aetna ID Number (claim cannot be processed without number)
Rx Group Number
Member Name (First, Middle, Last)
Gender
Member Birthdate (MM/DD/YYYY)
Male
Female
Member Address (Street, City, State, Zip Code)
Member Signature
Telephone Number
Date
(
)
Indicate reason for manually
Coordination of Benefits
filing these claims:
I had not received my Aetna ID card
Pharmacy not participating in network – provide explanation below, or on a separate sheet
Pharmacy unable to process claim electronically
Emergency – If Emergency, describe Emergency below, or on a separate sheet
Manual submission of claims does not guarantee reimbursement of claim.
Describe Emergency or Provide Explanation
Pharmacy Information
Please attach detailed prescription receipts or ask your pharmacist to complete the remaining
information. We cannot process your claim without this information.
Date Filed
Rx Number
RX (Check one)
Quantity
Days
National Drug Code (11 digit)
(MM/DD/YYYY)
Supply
New
Refill
Medication Name, Strength & Dosage Form
Doctor Name & DEA Number
DAW (Check one)
RX Price (including tax)
Name:______________________
0
1
2
DEA #: _____________________
3
4
5
Date Filed
Rx Number
RX (Check one)
Quantity
Days
National Drug Code (11 digit)
(MM/DD/YYYY)
Supply
New
Refill
Medication Name, Strength & Dosage Form
Doctor Name & DEA Number
DAW (Check one)
RX Price (including tax)
Name:______________________
0
1
2
DEA #: _____________________
3
4
5
Date Filed
Rx Number
RX (Check one)
Quantity
Days
National Drug Code (11 digit)
(MM/DD/YYYY)
Supply
New
Refill
Medication Name, Strength & Dosage Form
Doctor Name & DEA Number
DAW (Check one)
RX Price (including tax)
Name:______________________
0
1
2
DEA #: _____________________
3
4
5
Place Pharmacy Label here or enter:
Pharmacy Name
Pharmacist Signature Required
Date
Street Address
NABP Number
National Provider Identifier
City
Zip Code
Pharmacy Telephone Number
State
(
)
GC-1554 (9-06)
R-POD
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