Prescription Reimbursement Standard Claim Form
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214423-0206
Prescription Reimbursement Standard Claim Form
Important!
* Always allow up to 21 days from the time you send this form until the time you receive the response to
allow for mail time plus claims processing.
* Make a copy of all documents submitted and do not staple or tape receipts or attachments to this form.
No documents will be returned.
1
Primary Member/Patient Information
This section must be fully completed to ensure proper reimbursement of your claim.
Primary Member Information
Identification Number (refer to your prescription card)
Group No./Group Name
Name (Last Name)
(First Name)
(MI)
Address
City
State
Zip
Patient Information–Use a separate claim form for each patient.
ID No. and Patient Codes will be found on your prescription card.
Name (Last Name)
(First Name)
(MI)
Date of Birth
Male
Female
Relationship to Primary member
Full-Time College Student
Member
Spouse
Child
Other ____________
Yes
No
Important! A signature is REQUIRED in both A and B.
Fraud Prevention Regulation:
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.
A
x
Signature of Plan Participant
Date
Release of Information:
I certify that I (or my eligible dependent) have received the medicine described herein
and that the plan participant named is eligible for prescription benefits. I also certify that the medicine received is not
for treatment of an on-the-job injury or covered under another benefit plan. I authorize release of all information
pertaining to this claim to Caremark, the prescription benefit manager; insurance underwriter; sponsor; policyholder;
and/or employer. I certify that all the information entered on this form is correct.
B
x
Signature of Plan Participant
Date
2
Prescription Claim
NOTE: If you are including all original receipts with the following information, it is not necessary to complete
this section. Exception:If submitting compound receipts, this section must be completed.
Information
ONLY INCLUDE charges for prescription medications, original receipts and full itemized statements.
H
H
H
H
For office use only
New
Refill
DAW
Compound
Rx #
Date Filled (m/d/y)
Prescriber’s DEA No.
Prior Approval Code
Rx
Drug Name and Strength
Metric Quantity
Days Supply
Total Charges
N D C #
•
P.O. Box 3223
•
Wilkes-Barre, PA 18773-3223
(Over)
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