Form Bcbs 13177-1006r Sr - Prescription Drug Program Subscriber Claim Form

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Instructions for Completing the
Prescription Drug Program Subscriber Claim Form
Please note: One pharmacy and one subscriber per claim form
I. Subscriber and Patient Information: This section must be filled out in its entirety for claims to
be processed. The ID Number can be found on the subscriber’s Blue Cross and Blue Shield of
Florida ID card.
II. Patient Information: This section must also be filled out in its entirety for claims to be
processed.
III. Pharmacy Information: The Pharmacy NABP number is a unique ID number assigned to each
pharmacy and is required for claims processing. If this number is not found on the subscriber’s
receipt, it may be obtained from the pharmacy.
IV. Prescription Information: Prescription Receipts are required for claims processing. Cash
register receipts are not acceptable. Balance due field should be filled in when other insurance
has paid as primary and a balance due is being requested.
V. Subscriber Certification: The subscriber must sign the Subscriber Certification for claims to be
processed.
Mail completed claim form and receipts to:
Prime Therapeutics LLC
Mail Route – BCBSFL
P.O. BOX 14430
Lexington, KY 40512-4430

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