Orally Administered Cancer Medication Coverage Claim Form
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Orally Administered Cancer Medication Coverage Claim Form
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THIS FORM CAN BE DOWNLOADED FROM OUR WEBSITE AT
PART I – TO BE COMPLETED BY SUBSCRIBER
1. Subscriber’s Name: _______________________________________________________________ ____________________ ______
Last
First
MI
2. Date of Birth: _____ / _____ / ________
3. Sex
M
F
MM
DD
YYYY
4. Subscriber Identification Number: ________ ______________________________
Prefix
Number Portion
(Including 3HZN if applicable)
5. Address: __________________________________________________________________________________________________
5.
City: _____________________________ State: _______ ZIP: ___________ Telephone Number: _______ – _______ – __________
6. Group/employer name (if applicable): _____________________________________ 7. Group number: _______________________
8. Patient’s Name: __________________________________________________________________ ____________________ ______
Last
First
MI
9. Date of Birth: _____ / _____ / ________ 10. Relationship to the Subscriber:
Self
Spouse/CU/DP
Child Other: __________
MM
DD
YYYY
Subscriber’s Signature: ____________________________________________________________ Date: _____ / _____ / ________
MM
DD
YYYY
PART 2 –CLAIM INFORMATION -
Please use a separate claim form for each patient
You MUST include all original cash register receipts and patient information leaflets in order for your claim to process. The
minimum information required is:
• Patient Name
• National Drug Code (NDC)
• Date Filled
• Metric Quantity
• Days’ Supply
• Pharmacy Name
• Medication Name and Strength
• Total Charge / Rx Price
• Member’s Cost Sharing (Copayment, Coinsurance, Deductible)
PART 3 - Coordination of Benefits (COB) - Other Insurance Information
Is the medicine covered under any other group insurance?
Yes
No
If yes, is other coverage:
Primary
Secondary
If other coverage is Primary, include the Explanation of Benefits (EOB) with this form.
Name of Insurance Company: _______________________________________________________ ID #: _______________________
AUTHORIZATION
I certify that the information provided on this claim form is correct and complete, and that I am claiming benefits only for charges
actually incurred by the patient named.
I authorize any hospital, physician, pharmacy or other provider who participated in the care and treatment of the patient to release to
Horizon Blue Cross Blue Shield of New Jersey all medical or other information requested for the processing of this claim form. I hereby
agree to reimburse Horizon BCBSNJ; in full should this claim be incorrectly paid.
____________________________________________________________________________
______________________________
X Signature of Member
Date
SEE BACK OF THIS FORM FOR IMPORTANT INFORMATION
An Independent Licensee of the Blue Cross and Blue Shield Association.
5337 (E0313)
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