Prescription Drug Claim Form - Medicare Part D Page 3
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3C. Claim(s) Information
1. Is this a compound Rx?
Fill
Rx Number
Quantity
Days Supply
Strength/Dosage
Yes No
Date
National Drug
Medication
Charge (including tax)
Prescriber
Prescriber ID
/
/
Code (NDC)
Name
Name
Was this prescription filled in a foreign country? Ye s
Prescriber Fax Number:
No
2. Is this a compound Rx?
Fill
Rx Number
Quantity
Days Supply
Strength/Dosage
Yes No
Date
National Drug
Medication Name Charge (including tax)
Prescriber
Prescriber ID
/
/
Code (NDC)
Name
Was this prescription filled in a foreign country? Y e s
Prescriber Fax Number:
N o
3. Is this a compound Rx?
Fill
Rx Number
Quantity
Days Supply
Strength/Dosage
Yes No
Date
National Drug
Medication
Charge (including tax)
Prescriber
Prescriber ID
/
/
Code (NDC)
Name
Name
Was this prescription filled in a foreign country? Y e s
Prescriber Fax Number:
N o
Compounds
Even if you have itemized receipts, the following must be completed by your pharmacist if the
prescriptions being submitted for reimbursement are compound medications.
NDC Number
Ingredient
Quantity
Cost
Compounding Fee
D. Authorization
National Provider Indicator (NPI) Number
Pharmacy Name
Pharmacist/Physician Name
Pharmacy/Physician Address
City
State
Zip Code
Physician/Pharmacy Phone Number
Pharmacist/Physician Signature:
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