Prescription Drug Claim Form

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Prescription Drug Claim Form
Use this claim form to request reimbursement for prescription drugs purchased:
Between the effective date of your prescription coverage and the receipt of your card.
When prescription drugs are purchased at a non-participating pharmacy.
(Note: Only if allowed by your plan)
When filling out claim form (reverse side):
Complete a separate form for each family member for whom prescription drugs were purchased.
Complete the top portion of the form in full. Incomplete forms will be returned to you.
Attach a copy of your prescription receipt to the Prescription Drug Claim Form.
Include these numbers from your prescription card:
Cardholder’s (insured) Identification (ID) Number.
4-digit Carrier/Plan/Group Code.
Person Code: Three-digit number assigned to individual family member.
When form is complete:
(Please do not send forms until you receive your prescription card).
Fold with address on outside and affix postage.
ALL INCOMPLETE FORMS WILL BE RETURNED FOR COMPLETION.
If you have any questions, please call Restat’s Customer Service at 1-800-248-1062.
Customer Service Hours of Operation: M-F 7AM-1AM CST; SAT & SUN 8AM-5PM CST
FOLD WITH ADDRESS ON OUTSIDE, AFFIX POSTAGE AND MAIL
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FROM:
AFFIX
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POSTAGE
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Restat, a Catamaran Company
Patient Reimbursement
11900 W. Lake Park Drive
Milwaukee, WI 53224

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