Fillable Form Gc-1652 - Commercial Prescription Drug Claim Form printable pdf download

Commercial Prescription Drug

Aetna Pharmacy Management

PO Box 52444

Claim Form

Phoenix, AZ 85072-2444

FAX: 1-888-472-1128

Aetna Member Number (claim cannot be processed without number)

Group Number

If you are enrolled in Medicare, check here

Employee Birthdate (MM/DD/YYYY)

Employee Name (First, Middle, Last)

Employee Address (Street, City, State, ZIP Code)

Company Name & Address (Street, City, State, ZIP Code)

Employee Signature

Telephone Number

Date

(

)

Prescription(s) were for:

Patient Birthdate (MM/DD/YYYY)

Employee

Spouse

Dependent

Last Name, First, Middle Initial

Gender

Male

Female

Are any family members expenses covered by another group health plan, group pre-payment plan (Blue Cross-Blue Shield, etc.), no fault auto insurance,

Medicare, or any federal, state, or local government plan?

Yes

If Yes, list policy or contract holder, policy or contract number(s) and name/address of insurance company or administrator.

If Medicare, check all that apply.

Medicare Part A

Medicare Part B

Medicare Part D

Member Birthdate (MM/DD/YYYY)

Member ID Number with Other Carrier

Member Name

Indicate reason for manually filing these claims:

Coordination of Benefits – Please attach an Explanation of Benefits from the primary carrier along with the detailed receipt.

Emergency – If Emergency, describe Emergency below, or on a separate sheet.

Compound Drug – If you have a drug that contains more than 1 ingredient. Please provide the following information:

• The VALID 11-digit NDC number for EACH ingredient used in the compound prescription.

• The ingredient name for each NDC.

• The “metric quantity” expressed in number of tablets, grams or milliliters for each ingredient NDC #.

• The cost for EACH ingredient (dollar amount).

• The TOTAL compounded quantity.

• The TOTAL dollar amount paid by the patient.

Please Note: Manual submission of claims does not guarantee reimbursement of claim.

Pharmacy Information

Please attach detailed prescription receipts or ask your pharmacist for a pharmacy statement. We cannot

process your claim without this information.

Member

Submission Requirements

• Please read carefully before completing this form. Claim

You MUST include all original “pharmacy” receipts in order for your

claim to process. “Cash register” receipts WILL NOT be accepted

forms without the required information cannot be

with the exception of Diabetic Supplies. The minimum information

processed. Incomplete forms will be returned to you.

that must be included on your pharmacy receipts is listed below:

• If you use more than one pharmacy, use a separate form for

• Patient Name • Prescription Number • Medicine NDC number

each pharmacy.

• Date of Fill • Metric Quantity • Total Charge

• Use a separate claim form for each patient.

• Days Supply for your prescription (you need to ask your pharmacist for

• Claims must be submitted within two years of date of

this “Day Supply” information)

purchase.

• Pharmacy Name and Address or Pharmacy NABP Number

• Complete all employee and patient information on the top

portion of the form and be sure to sign it.

If the Prescribing Physician’s NPI (National Provider Identification)

• Mail or FAX the Prescription Drug Claim Form to:

number is from a foreign country, please fill in below:

Aetna Pharmacy Management

Country:

PO Box 52444

Currency:

Phoenix, AZ 85072-2444

Amount:

FAX: 1-888-472-1128

GC-1652 (3-14) A

R-POD

Form Gc-1652 - Commercial Prescription Drug Claim Form

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