Fillable Prescription Drug Claim Form - Florida Bcbs printable pdf download

Prescription Drug Claim Form

DIRECTIONS:

1. Complete and sign claim form below. Use a separate form for each patient.

2. Attach Explanation of Benefits (if applicable) and Prescription Receipts.

3. Send completed Form & Pharmacy receipts to:

PRIME THERAPEUTICS, LLC; P.O. Box 14430; Lexington, KY 40512-4430

I. POLICY HOLDER INFORMATION

POLICY HOLDER NAME (LAST, FIRST, MIDDLE)

MEMBER ID NUMBER

DATE OF BIRTH (MM/DD/YYYY)

GROUP NUMBER

STREET ADDRESS

SEX

□

MALE

CITY, STATE, ZIP CODE

□

FEMALE

II. PATIENT INFORMATION

(Must be completed if patient is a dependent child or spouse.)

DATE OF BIRTH (MM/DD/YYYY)

PATIENT NAME (LAST, FIRST, MIDDLE)

ADDRESS (If different than member)

SEX

RELATIONSHIP

□

MALE

SPOUSE

CHILD

□

CITY, STATE, ZIP CODE

FEMALE

DISABLED DEPENDENT CHILD

III. GENERAL INFORMATION

□

A. Was condition related to an accident?

YES

Accident Date (MM/DD/YYYY)

_________________________________≤

□

If yes, was it related to:

Auto Accident

Workers’ Comp

Other __________________________________________________________________________

□

B. Is other insurance applicable to charge?

YES

If yes, complete the information below. You must submit an Explanation of Benefits (EOB) for your claim to be processed.

Other Carrier Name ________________________________________________

Policy # _____________________________________________________________

Name of Policy Holder______________________________________________

Amount Paid By Other Insurance $ _______________________________________

IV. PHARMACY INFORMATION

The Pharmacy NCPDP number can be found on the pharmacy receipt, or may be obtained from the pharmacy.

PHARMACY NAME

NCPDP #

NPI #

PHONE

STREET ADDRESS

CITY, STATE, ZIP CODE

PHARMACIST SIGNATURE

PHARMACIST LICENSE NUMBER

V. PRESCRIPTION INFORMATION

Prescription receipts are required for processing. Cash register receipts are not acceptable. Ensure each receipt shows the information below. Ask your

pharmacist to provide any missing information. A pharmacy patient history may be submitted in lieu of a receipt, but must be signed by the pharmacist.

• Patient Name

• Pharmacy Name and Address

• Drug Name and NDC#

• Fill Date

• Prescription Number

• Total Charge

• Days Supply

• Quantity

• Doctor Name and DEA#

• DAW (Dispense as Written Code)

VI. CERTIFICATION

I certify all information provided on this form and on the attached itemized statement to be true and correct to the best of my knowledge. I understand

that any person who knowingly and with intent to injure, defraud or deceive any insurer, or files a statement of claim or application containing any false,

incomplete or misleading information is guilty of a felony of the third degree.

POLICY HOLDER/PATIENT SIGNATURE

DATE

□

Reason for mailing in claim:

System not available at pharmacy

My information not on file at pharmacy

Non-participating pharmacy

□

Pharmacy would not submit claim

I had not received my Florida Blue card yet

Extension of benefits