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 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
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
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.