Form C3001 - Coordination Of Benefits/direct Claim Form (Page 2 of 2) in pdf

Claim Receipts

Please tape your receipts here. Do not staple! If you have additional receipts, tape them on a separate piece of paper.

Tape receipt for prescription 1 here.

Tape receipt for prescription 2 here.

Receipts must contain the

following information:

• Date prescription filled

• Name and address of pharmacy

• Doctor name or ID number

• NDC number (drug number)

• Name of drug and strength

• Quantity and days’ supply

• Prescription number (Rx number)

• DAW (Dispense As Written)

• Amount paid

PHARMACY INFORMATION (For Compound Prescriptions ONLY)

• List the VALID 11-digit NDC number for

Date

Days’

Rx #

EACH ingredient used for the compound

filled

supply

prescription.

• For each NDC number, indicate the “metric

VALID 11-digit NDC #

Quantity

Price

quantity” expressed in the number of

tablets, grams, milliliters, creams, ointments,

injectables, etc.

• For each NDC number, indicate cost per

ingredient.

• Indicate the TOTAL charge (dollar amount)

paid by the patient.

• Receipt(s) must be attached to claim form.

Total quantity

Total charge

When To Use This Form

Instructions

• Use this form to submit claims under Coordination of Benefit rules.

Read carefully before completing this form.

• You must complete a separate claim form for each pharmacy used and for each patient.

1. Be sure your receipts are complete. In

• You must submit claims within 1 year of date of purchase or as required by your plan.

order for your request to be processed, all

Another Health Plan Paid

receipts must contain the information

listed above. Your pharmacist can provide

You must first submit the claim to the primary insurance carrier. Once the statement from the

the necessary information if your claim or bill

primary plan is received from the primary carrier, complete this form, tape the original

is not itemized.

prescription receipts in the spaces provided above, and attach the statement from the primary

plan, which clearly indicates the cost of the prescription and what was paid by the primary plan.

2. The plan member should read the

acknowledgment carefully, and then sign

Prescription Drug Programs or HMO Plans

and date this form.

Retail pharmacies: If the primary plan is one in which a co-payment or coinsurance is paid at

3. Return the completed form and

the pharmacy, then no EOB is needed. Just complete this form and attach the prescription

receipt(s) to:

receipt(s) that shows the co-payment or coinsurance amount paid at the pharmacy. The

receipt(s) will serve as the EOB.

Express Scripts

P.O. Box 14711

The Medco Pharmacy: If the primary plan is mail order, complete this form and attach either

Lexington, KY 40512

the prescription receipt(s) that shows the co-payment or coinsurance amount paid to the

mail-order pharmacy or the statement of benefits you receive from the mail-order pharmacy.

* California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents

false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Pennsylvania: 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.

*C3001*

Visit us online anytime at

C3001

9-12

*C3001*

Form C3001 - Coordination Of Benefits/direct Claim Form Page 2

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