Reimbursement Claim Form - Prescription Drug Card
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2P R E S C R I P T I O N D R U G C A R D
R E I M B U R S E M E N T C L A I M F O R M
Not to be used for BlueSCRIPT reimbursement.
P L E A S E T Y P E O R P R I N T C L E A R LY.
Must be fully completed for reimbursement of your drug claim.
P A R T 1 : M E M B E R I N F O R M AT I O N
Member ID number __________________________________ Group number ___________________ PCN number
IL _______
(bottom face of ID card)
Member name __________________________________________________ Member phone _________________________________________________
Address _________________________________________________ City ____________________________ State ________ Zip _________________
Patient Information — Use a separate claim form for each family member
Patient name ___________________________________________ Social Security No.___________________ Date of birth ____________________
Ì Member
Ì Spouse
Ì Child
Ì Other _____________________________
Ì Male Ì Female
Relationship:
Patient:
Are any of these medications being taken for an on-the-job injury? . . . Ì Yes . . . Ì No
Is the medication covered under any other group insurance? . . . . Ì Yes . . . Ì No
If yes, is other coverage: Ì Primary Ì Secondary
If other coverage is Primary, include the explanation of benefits (EOB) with this form.
Name of insurer ______________________________ Policy number _____________ ID number ___________________ Phone _______________
I certify that all the information entered on this form is correct. In addition, I also certify that I (or my eligible dependent) have received the medication described herein and that the patient named
is eligible for drug benefits. I also certify that the medication received is not for treatment of an on-the-job injury or covered under another benefit plan. I understand that Blue Cross and Blue
Shield’s use or disclosure of individually identifiable health information, whether furnished by me or obtained from other sources such as medical providers, shall be in accordance with the federal
privacy regulations under HIPAA (Health Insurance Portability and Accountability Act of 1996).
X___________________________________________________________________________________________ __________________________________
Signature of Patient or Legal Representative
Date
Please remember to include all original pharmacy receipts.
P A R T 2 : I M P O R T A N T
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I
I
I
I
Receipts must include:
Pharmacy name
Prescription
Drug name
Quantity
NDC number
I
I
I
I
number
Strength
Date purchased
Drug charge
Days supply
Pharmacist to complete this section ONLY if original pharmacy receipts are not included.
P A R T 3 : P H A R M A C Y I N F O R M AT I O N
I
To ensure that your patient receives accurate and timely reimbursement for medication purchases, please assist in completing the information below.
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If compound prescriptions, please enter COMPOUND RX in the space designated for the NDC number and complete the compound section
on the reverse side.
Pharmacy name ___________________________________________ _ _ Pharmacy NABP number ___________________________________________
Pharmacy address ____________________________________________________________________________________________________________
City _____________________________________________ State _________ Zip _______________ Phone __________________________________
I hereby certify that all the information listed below is correct and represents the actual charge(s) for prescription(s) dispensed. I further
understand that all benefit payments as related to the charges listed below will be paid directly to the member.
X___________________________________________________________________________________________ __________________________________
Signature of Pharmacist or Representative (Required only if original pharmacy receipts are not included)
Date
Ì
Ì
Rx number
Date filled
Prescriber’s DEA number
Ì
New
Ì
Refill
Prior approval code
(mo/dy/year)
DAW
Compound
For office use only
Rx 1
NDC number
Drug name and strength
Metric quantity
Days supply Total charge
Ì
Ì
Ì
Ì
Rx number
Date filled
Prescriber’s DEA number
New
Refill
Prior approval code
(mo/dy/year)
DAW
Compound
For office use only
Rx 2
NDC number
Drug name and strength
Metric quantity
Days supply Total charge
Ì
Ì
Ì
Ì
Rx number
Date filled
Prescriber’s DEA number
New
Refill
Prior approval code
(mo/dy/year)
DAW
Compound
For office use only
Rx 3
NDC number
Drug name and strength
Metric quantity
Days supply Total charge
Fraud Prevention: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material
thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
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