14423-STANDARD-0814
Prescription Reimbursement Claim Form
Important!
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Always allow up to 30 days from the time you receive the response to allow for mail time plus claims processing.
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Keep a copy of all documents submitted for your records.
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Do not staple or tape receipts or attachments to this form.
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Reimbursement is not guaranteed and other contractor will review the claims subject to limitations, exclusions
and provisions of the plan.
STEP 1
Card Holder/Patient Information
This section must be fully completed to ensure proper reimbursement of your claim.
Card Holder Information
Identification Number (refer to your prescription card)
Group No./Group Name
Name (Last Name)
(First Name)
(MI)
Address
Address 2
City
State
Zip
Country
Patient Information–Use a separate claim form for each patient.
Name (Last Name)
(First Name)
(MI)
Date of Birth
Male
Female
Phone Number
Relationship to Primary member
Spouse
Other_______________
Member
Child
Other Insurance Information
COB (Coordination of Benefits)
Are any of these medicines being taken for an on-the-job injury?
Yes
No
Is the medicine covered under any other group insurance?
Yes
No
If yes, is other coverage:
Primary
Secondary
If other coverage is Primary, include the explanation of benefits (EOB) with this form.
Name of Insurance Company____________________________ ID#________________________
Important! A signature is REQUIRED
NOTICE
Any person who knowingly and with intent to defraud, injure, or deceive any insurance company, submits a claim or application containing any
materially false, deceptive, incomplete or misleading information pertaining to such claim may be committing a fraudulent insurance act which is a
crime and may subject such person to criminal or civil penalties, including fines, denial of benefits, and/or imprisonment.
I certify that I (or my eligible dependent) have received the medicine described herein. I certify that I have read and understood this form, and that all
the information entered on this form is true and correct.
X
Date
Signature of Plan Participant
(Over)