Form Gc-1360 - Aenta Prescription Drug Claim Form
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1
2Aetna
Prescription Drug Claim Form
Pharmacy Management
Attn: Claim Processing
P.O. Box 398106
Minneapolis, MN 55439-8106
Social Security Number/Member Number
Group Number
(claim cannot be processed without number)
Employee Name (First, Middle, Last)
Employee Birthdate (MM/DD/YYYY)
Employee Address (Street, City, State, Zip Code)
Company Name & Address (Street, City, State, Zip Code)
Employee Signature
Telephone Number
Date
(
)
Prescription(s) were for:
Employee
Spouse
Dependent
Last Name, First, Middle Initial
Sex
Patient Birthdate (MM/DD/YYYY)
Male
Female
Indicate reason for manually filing
Coordination of Benefits
I had not received my Aetna ID card
Travel Supply
these claims:
Pharmacy not participating in network
Pharmacy unable to process claim electronically
Emergency – If Emergency, describe Emergency below, or on a separate sheet
Describe Emergency
Pharmacy Information
Please attach prescription receipts or ask your pharmacist to complete the remaining information. We
cannot process your claim without this information.
1) Date Filed
Rx Number
RX (Check one)
Quantity
Days Supply National Drug Code (11 digit)
(MM/DD/YYYY)
New
Refill
Medication Name, Strength & Dosage Form
Doctor Name & DEA Number
DAW (Check one)
RX Price (including tax)
_____________________
Name:
0
1
2
_____________________
DEA #:
3
4
5
2) Date Filed
Rx Number
RX (Check one)
Quantity
Days Supply National Drug Code (11 digit)
(MM/DD/YYYY)
New
Refill
Medication Name, Strength & Dosage Form
Doctor Name & DEA Number
DAW (Check one)
RX Price (including tax)
_____________________
Name:
0
1
2
_____________________
DEA #:
3
4
5
3) Date Filed
Rx Number
RX (Check one)
Quantity
Days Supply National Drug Code (11 digit)
(MM/DD/YYYY)
New
Refill
Medication Name, Strength & Dosage Form
Doctor Name & DEA Number
DAW (Check one)
RX Price (including tax)
_____________________
Name:
0
1
2
_____________________
DEA #:
3
4
5
Place Pharmacy Label here or enter:
Pharmacy Name
Pharmacist Signature
Date
Street Address
NABP Number
City
State
Zip Code
Pharmacy Telephone Number
(
)
GC-1360 (4-03)
R-POD
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Parent category: Business