Reimbursement Claim Form - Prescription Drug Card Page 2
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2IT IS TO YOUR ADVANTAGE TO ALWAYS USE YOUR PRESCRIPTION DRUG CARD TO AVOID FILING PAPER CLAIMS, WHICH DELAYS
Reminder: DO NOT use this form for BlueSCRIPT reimbursement.
PAYMENT OF YOUR BENEFITS.
I N S T R U C T I O N S
To avoid delays in handling your claim, be sure all information is complete and correct.
A separate claim form must be completed for:
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Each patient
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Each pharmacy from which you purchase prescription drugs, if original receipt(s) is not attached
C L A I M S U B M I S S I O N
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When submitting a claim, the following information
DO NOT include charges for durable medical
must be included:
equipment which required a prescription to obtain.
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Pharmacy name
Quantity
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DO NOT submit canceled checks or cash register
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Prescription number
Drug Charge
slips. These are not acceptable as substitutes for
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original receipts.
Date of purchase
Computer print-out
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Drug name
Pharmacist’s signature and/or original
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DO NOT submit statement with balance
pharmacy receipt(s)
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Drug strength
amounts only.
H O W T O C O M P L E T E T H I S F O R M
Member/Patient Information — Complete all member and patient information in Part 1 on reverse side.
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The member ID number, group number and PCN number can be found on your member ID card.
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Sign and date in the space provided. Your signature certifies that the information is correct and complete.
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Complete a separate form for each family member and for each pharmacy.
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See your benefit administrator for additional claim forms, or log on to our Web site at to download additional
forms. Mail your completed form to the address shown below.
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Please make a copy of all documents and receipts before you send in your claim(s) as no documents will be returned.
P H A R M A C Y I N F O R M AT I O N
Pharmacist to complete Part 3 of the form
C O M P O U N D P R E S C R I P T I O N S
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Include Rx number(s), drug name(s), strength(s) and date filled.
For pharmacy use only
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NDC number
Drug ingredient
Quantity
Charge
Include NDC number(s) for the drug(s) dispensed.
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Indicate NABP number, pharmacy address and phone number.
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If a compound prescription, enter the NDC number of the most
expensive ingredient of the legend drug used.
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Indicate the drug ingredient(s) and quantity.
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Indicate the “metric quantity” expressed in number of tablets, grams
or mls for liquids, creams, ointments and injectables.
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Indicate the days supply (number of days the medication will last).
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Indicate the amount paid by the patient.
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Sign and date the form.
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Pharmacist questions? Call Prime Therapeutics’ Contact Center at 800.821.4795.
M A I L I N G I N S T R U C T I O N S
Mail this form and your original paid pharmacy receipt(s) to:
Blue Cross and Blue Shield of Illinois
P.O. Box 64812
St. Paul, MN 55164-0812
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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