Enrollee Prescription Drug Claim Form
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2Cigna Medicare Services
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Enrollee Prescription Drug Claim Form
REASON FOR REIMBURSEMENT
This claim form can be used to request reimbursement of covered expenses. You may select one of the reasons below to
tell us more about your request. Note that the use of a claim form, such as this Enrollee Prescription Drug Claim Form, is
not required to receive a reimbursement.
I did not use my prescription drug ID card
I was waiting for a drug approval
Non-participating pharmacy (Please explain)
I was retroactively enrolled with the plan
________________________________________
I filled a compound prescription (Please have your
Primary coverage is with another insurance carrier.
pharmacist fill out the compound prescription area
Please provide explanation of benefits (EOB) or
of this form)
denial letter from the primary insurance carrier
Other/explanation: ________________________
_______________________________________
ENROLLEE INFORMATION
ID number (on the front of your prescription drug ID card):
RxPCN (on the front of your prescription drug ID card):
Enrollee name:
Enrollee birth date:
Month _________ Day _____ Year _____
Enrollee sex:
Male
Female
ENROLLEE CERTIFICATION
I represent that the enrollee information entered on this form is correct, that the enrollee named is eligible for the
benefits and that the enrollee has received the medication described. I also represent that the medication received is
not for treatment of an on-the-job injury. I also authorize release of all information pertaining to this claim to the plan
administrator or its designees.
Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application
for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of
misleading, information concerning any material fact thereto, commits a fraudulent insurance act which is a crime.
Enrollee signature:
Date:
Daytime phone number:
PRESCRIPTION INFORMATION
Use this section for brand and generic medication refund requests.
(See the next section for compound prescription refund requests.)
1) Date filled
Rx number
Quantity
Day supply
Drug name and strength
11-digit NDC number
Amount paid
$
Prescribing doctor’s name
Doctor’s phone number
Pharmacy name and address
Pharmacy NABP
2) Date filled
Rx number
Quantity
Day supply
Drug name and strength
11-digit NDC number
Amount paid
$
Prescribing doctor’s name
Doctor’s phone number
Pharmacy name and address
Pharmacy NABP
803127 f Rev. 09/2013
S5617_14_11020
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