Prescription Reimbursement Standard Claim Form Page 2

Pharmacy Information

NOTE: The pharmacist is to complete this section ONLY if original pharmacy

receipts are not included or if there is a compound prescription.

Pharmacy Name

Pharmacy NABP No.

Pharmacy Phone Number

(

)

I hereby certify that all the information listed below is correct and represents the actual charge(s) for prescription(s) dispensed. I further

understand that all benefit payments as related to the charges listed below will be paid directly to the cardholder.

Signature of Pharmacist or Representative

Date

Mail This Completed Form To:

Please refer to your prescription card to ensure this form is mailed to

the proper address.

IF 610415 IS THE RXBIN # ON YOUR CARD MAIL THE COMPLETED FORM TO:

Caremark

P.O. Box 52116

Phoenix, Arizona 85072-2116

IF 004336 IS THE RXBIN # ON YOUR CARD MAIL THE COMPLETED FORM TO:

Caremark

P.O. Box 52136

Phoenix, Arizona 85072-2136

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