Prescription Drug Claim Form - Medicare Part D printable pdf download

Prescription Drug Claim Form - Medicare Part D

Instructions for using this form:

1. Present your prescription drug card at the pharmacy to avoid having to submit this drug claim

form for reimbursement.

2. If necessary, use this form for prescription claims that were purchased without presenting your card

due to an emergency or at a non-participating pharmacy. For consideration of payment, you must

send all of the requested information for each claim at the address below. If the information is

complete your claim(s) will be processed within 14 days. Your reimbursement request may be

denied if you submit incomplete information and we are unable to obtain the information from your

pharmacy or physician.

3. Complete all items in sections (A) and (B). Sign the form in the area provided. Enclose

original receipts with this form. Be sure your itemized receipts include the following:

o Pharmacy Name

o Strength

o Pharmacy NABP Number

o Quantity Dispensed

o Prescription Number

o Physician ID Number

o Date of Purchase

o Total Amount Charged For Each

o Medicine Name

Prescription

Please make copies for your records.

4. If your claim is for a compound drug or you are not able to submit original pharmacy

receipts, please have your pharmacist or physician complete sections (C) and (D) of this

form.

5. Items not covered under your prescription benefit plan should not be submitted for reimbursement

including Durable Medical Equipment. Diabetic supplies requiring a prescription are

reimbursable only if covered by your plan.

6. Mail completed form to: Blue Cross Blue Shield of Massachusetts, Medicare Advantage,

Appeals Coordinator, P.O. Box 55007, Boston, MA 02205

This document is available in other formats. For more information, call 1-800-200-4255, 8:00 a.m. to

8:00 p.m. Eastern Time, seven days a week, January 1 through February 14 and October 1 through

December 31. From February 15 through September 30, you can call us 8:00 a.m. to 8:00 p.m. Eastern

Time, Monday through Friday. TTY users call 711.

Blue Cross and Blue Shield of Massachusetts is a HMO and PPO plan with a Medicare contract.

Enrollment in Blue Cross Blue Shield of Massachusetts depends on contract renewal.

Blue Cross Blue Shield of Massachusetts is an Independent Licensee of the Blue Cross and

Blue Shield Association

All beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-

routine circumstances. Quantity limitations and restrictions may apply.

Prescription Drug Claim Form - Medicare Part D