Prescription Drug Claim Form - Medicare Part D Page 2

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Today’s Date:
A. Cardholder - Information
Cardholder’s Name (Last, First, MI)
Cardholder ID Number
Address
City
State
Zip Code
Cardholder’s Date of
Gender
 M  F
Birth
/
/
Cardholder Telephone Number
Plan Name
Why was the prescription drug card NOT used for this purchase? Please explain below:
B. Other Insurance Coverage
Is cardholder eligible for primary prescription drug coverage from another provider?  Yes  No
If yes, please use that insurance card to complete the fields below. Please also include a copy of
the Explanation of Benefits from that provider when submitting this drug claim form.
Insured’s Name (Last, First, MI)
Other Insurance Company’s Name
Member ID
PCN #
Coverage Effective Date
/
/
Cardholder Signature: _____________________________ Date:
Reimbursement of submitted claims is subject to your prescription benefit program and not guaranteed.
Reimbursement will be according to the parameters of your prescription benefit plan. It will be
only for the amount your program would have paid on your behalf. The amount of reimbursement
may be significantly lower than the original amount you paid.
Information to be completed by your Pharmacist/Physician: By completing Sections C and D,
you certify the information correctly represents the amount paid by the member for the prescriptions
dispensed. You acknowledge that all payments related to these prescriptions will be paid to the
member.
If more than three (3) prescriptions are being submitted, please complete additional claim form(s).

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