MEDICARE PART D CLAIM FORM
Use this form to request reimbursement for covered medications purchased at retail cost. Complete one form
per member. Please print clearly. Additional information and instructions on back, please read carefully.
Member Information
Member ID (see ID card) Health Plan Name
Group/Employer Name Health Plan State
Last Name First Name MI
Mailing Street Address Apt. #
City State ZIP Date of Birth
(mm/dd/yyyy)
Physician and Pharmacy Information
Prescribing Physician Name Dispensing Pharmacy Name
Prescribing Physician Phone Number with Area Code Dispensing Pharmacy Phone Number with Area Code
Reason for Request
Select appropriate options for your request:
I did not use my prescription drug ID card.
I used a non-participating pharmacy for one of the following reasons:
I traveled outside my plan’s service area and needed my medication but could not access a network pharmacy.
I could not get my medication in a timely manner from either a network pharmacy located within a reasonable
driving distance or a network mail service pharmacy.
A non-network pharmacy located within a care institution (emergency department, provider based clinic,
outpatient surgery or other outpatient facility) dispensed my medication while I was a patient.
I was evacuated or displaced from my residence due to a state or federally declared disaster or health emergency.
I filled a compound prescription (your pharmacist must complete Section B on the back of this form).
My primary coverage is with another insurance carrier (coordination of benefits claim, see Section C on back for details).
I am submitting an Explanation of Benefits (EOB) from another health plan or Medicare.
Primary Health Plan Name: ___________________________________________________
I am submitting a copay receipt.
I was waiting for a drug approval.
I was retroactively enrolled with the plan.
My pharmacy billed the wrong plan.
Vaccine and/or vaccine administration
• Vaccine prescription filled at: Pharmacy Physician’s office
• Vaccine administered by: Pharmacy Physician’s office
• Applicable to cost of claim (select all that apply): Administration cost Vaccine cost
Other (please explain) ___________________________________________________________________________________
Acknowledgement
I certify that the patient for whom this claim is made is covered in this prescription drug program and that the prescription
is for the sole use of the named patient. I also certify that the claim(s) being submitted for payment are not eligible
for payment under a no-fault automobile or worker’s compensation insurance program. I also authorize release of all
information pertaining to this claim(s) to the plan administrator, underwriter, sponsored policy holder, and/or employer.
X _______________________________________________________________________ _________________________
Date
1
2
3
4
Member or Authorized Representative Signature
NOTE: If form is completed and signed by an Authorized Representative rather than
the member, an Authorization of Representation (AOR) must accompany the request
or Power of Attorney (POA) must be on file with the plan.
ORX5262E WF1478997
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signature
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