Medicare Part D Prescription Claim Form Page 2

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STEP 2
Submission Requirements:
You MUST include all original “pharmacy” receipts in order for your claim to process. “Cash register” receipts will only be
accepted for diabetic supplies. The minimum information that must be included on your pharmacy receipts is listed below:
• Patient Name
• Prescription Number
• Medicine NDC number
• Date of Fill
• Metric Quantity
• Total Charge
• Days Supply for your prescription (you need to ask your pharmacist for this “Day Supply” information)
• Pharmacy Name and Address or Pharmacy NABP Number
A valid Prescribing Physician’s NPI (National Provider Identification) number is required, please provide:________________
Additional Comments
STEP 3
Mailing Instructions:
Mail to :
CVS Caremark
P.O. Box 52066
Phoenix, AZ 85072-2066
IMPORTANT REMINDER
To avoid having to submit a paper claim form:
• Always have your card available at time of purchase.
• Always use pharmacies within your network.
• Use medication from your formulary list.
• If problems are encountered at the pharmacy, call the number on the back of your card.
15071-MED_D-0912
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