Prescription Reimbursement Claim Form Page 2
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1
2I N S T R U C T I O N S
To avoid delays in handling your claim, be sure all information is complete and correct.
A separate claim form must be completed for:
•
Each patient
•
Each pharmacy from which you purchase prescription drugs
C L A I M S U B M I S S I O N
When submitting a claim, the following information must be included:
•
Member Name
•
Pharmacy Name and Address or NABP Number
•
Prescription Number
•
Drug Strength/NDC Number
•
Date of Purchase
•
Metric Quantity/Days Supply
•
Drug Name
•
Original Pharmacy Receipts
•
Total Charge
DO NOT submit canceled checks, cash register slips or personal itemization. These are not acceptable as
substitutes for original receipts.
DO NOT submit statements with “balance” amounts only.
H O W T O C O M P L E T E T H I S F O R M
Cardholder/
Complete all cardholder and patient information in Part 1 on reverse side.
Patient
•
The cardholder ID number can be found on your ID card.
•
Sign and date in the space provided. Your signature certifies that the information
Information
is correct and complete.
•
Please make a copy of all documents and receipts before you send them to
FutureScripts. No documents will be returned.
P H A R M A C Y I N F O R M A T I O N
Pharmacist
•
Indicate pharmacy name, NABP number,
C O M P O U N D P R E S C R I P T I O N S
address and phone number.
to complete
For pharmacy use only
•
Include Rx number(s), drug name(s),
Part 3 of
NDC #
Drug Ingredient
Quantity
Charge
strength(s) and date filled.
the form
•
Indicate prescriber’s DEA number and
whether the prescription is new, refill,
DAW or compound.
•
Include NDC number(s) for the drug(s) dispensed.
•
Enter the NDC number of the most expensive
ingredient of the legend drug used in the
compound.
•
Indicate the drug ingredient(s) and quantity.
•
Indicate the “metric quantity” expressed in
number of tablets, grams or mls for liquids,
creams, ointments and injectables.
•
Indicate the “days supply” (the number of
days the medication will last).
•
Indicate the dollar amount paid by the patient.
•
Sign and date the form.
•
Pharmacist questions? Call 1-888-678-7012.
M A I L T H I S F O R M T O :
FutureScripts
Dept. #0382
PO Box 419019
Kansas City, MO 64141
If you have any questions, please call 1-888-678-7012.
2006-0137 (7/06)
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