Form Y0069 - Prescription Drug Claim Form Medicare Part D - Upmc Health Plan
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2UPMC Health Plan
PRESCRIPTION DRUG CLAIM FORM MEDICARE PART D
Patient Name (Last, First, MI)
Date of Birth
Gender
Patient ID Number
M
F
Check if new address
Street___________________________________________________________________________________
City/State________________________ Zip Code___________ Daytime Telephone ( ___ )_____________
Plan Name (Plan Type)
Group Number
♦ Is Medicare Part D the patient’s primary coverage?
yes
no
♦Does the patient have primary coverage under another plan, with Medicare considered secondary?
yes*
no
*If yes, please attach an explanation of benefits from your primary carrier.
PRESCRIPTION INFORMATION
IMPORTANT All prescription claims must have prescription receipts/labels which include:
Pharmacy Name/Address
Drug Name, Strength and NDC
Days Supply
Script Number
Patient’s Name
Date Filled
Price
Quantity
Please note: The above claim detail information is necessary in order to process your claim request.
Number of receipts attached: ________
Please tape receipts to separate piece of paper.
CASH REGISTER RECEIPTS ARE NOT ACCEPTABLE FOR ANY PRESCRIPTIONS.
(With the exception of diabetic supplies)
◊
Is claim for DIABETIC SUPPLY?
yes
no. If Yes, please ask your pharmacist which
supplies are covered under your Part-D plan. Please ensure receipts include:
Pharmacy Name/Address • Date Filled • Type of Insulin and/or Type of supply
• Quantity •Days Supply • Price •Patient’s Name.
Cash register receipts are acceptable but
Pharmacist Signature is required if any information is handwritten.
◊
Is this claim for allergy serum or vaccination?
yes
no
If yes, please supply type or additional information: ______________________________
PLEASE SIGN AND DATE HERE: I certify that all information provided is correct and that the
prescription(s) submitted are for me. I have received the medication, and I authorize release of all information
contained on this claim to Express Scripts, Inc., the company chosen by my Plan Sponsor to manage my
pharmacy benefit, and my Plan Sponsor. Any person who knowingly and with intent to defraud any insurance
company or other person who 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.
Patient’s Signature and Date _____________________________
_____
UPMC for Life Specialty Plan and UPMC for You Advantage is a Coordinated Care plan with a Medicare
Advantage contract and a contract with the Pennsylvania Medical Assistance (Medicaid) program. UPMC
for Life Options is a Coordinated Care plan with a Medicare Advantage contract.
This document is available in alternate formats or languages. For more information, call 1-800-606-8648,
8 a.m. to 8 p.m., seven days a week., TTY users call 1-866-407-8762, from February 15 through October 14,
2012 we are available from 8 a.m. to 8 p.m., Monday through Friday, and 8 a.m. to 3 p.m. on Saturday.
Y0069 11 163 CMS Approved 11/08/2010
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