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Commercial
Prescription Drug Claim Form
Aetna Pharmacy Management
PO BOX 52444
Phoenix, AZ 85072-2444
Fax Number: 1-888-472-1128
Aetna Member Number (claim cannot be processed without number)
Group Number
If you are enrolled in Medicare, check here
Student Name (First, Middle, Last)
Student Birthdate (MM/DD/YYYY)
Student Address (Street, City, State, ZIP Code)
School Name & Address (Street, City, State, ZIP Code)
Student Signature
Student Telephone Number
( )
Date
Prescription(s) were for:
Last Name, First, Middle Initial
Gender
Male Female
Student Spouse Dependent
Patient Birthdate (MM/DD/YYYY)
Are any family members expenses covered by another group health plan, group pre-payment plan (Blue Cross-Blue Shield, etc.), no fault auto insurance,
Medicare, or any federal, state, or local government plan?
No Yes
If Yes, list policy or contract holder, policy or contract number(s) and name/address of insurance company or administrator.
If Medicare, check all that apply.
Medicare Part A Medicare Part B Medicare Part D
Member's ID Number with Other Carrier
Member's Name
Member's Birthdate (MM/DD/YYYY)
Indicate reason for manually filing these claims:
Coordination of Benefits – Please attach an Explanation of
Benefits from the primary carrier along with the detailed receipt.
Emergency – If Emergency, describe Emergency below, or on a
separate sheet
Please Note: Manual submission of claims does not guarantee reimbursement of claim.
Pharmacy Information
Please attach detailed prescription receipts or ask your pharmacist for a pharmacy statement. We cannot
process your claim without this information.
Member
• Please read carefully before completing this form. Claim forms without the required information cannot be
processed. Incomplete forms will be returned to you.
• If you use more than one pharmacy, use a separate form for each pharmacy.
• Use a separate claim form for each patient.
• Claims must be submitted within two years of date of purchase.
• Complete all employee and patient information on the top portion of the form and be sure to sign it.
• Mail or FAX the Prescription Drug Claim Form to: Aetna Pharmacy Management
PO BOX 52444
Phoenix, AZ 85072-2444
Fax Number: 1-888-472-1128
GC-1564 (10-12) Page 1 of 2
Misrepresentation
Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for
insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties.
Attention Arkansas, District of Columbia, Rhode Island and West Virginia Residents: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime
and may be subject to fines and confinement in prison.
Attention California Residents: For your protection California law requires notice of the following to appear on this form: Any
person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.
Attention Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or
misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or
claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance
within the department of regulatory agencies.
Attention Florida Residents: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of
claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Attention Kansas and Missouri Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance
company or other person submits an enrollment form for insurance or statement of claim containing any materially false information or
conceals, for the purpose of misleading, information concerning any fact material thereto may have violated state law.
Attention Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a
statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime.
Attention Louisiana Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application is guilty of a crime and may be subject to fines and confinement in prison.
Attention Maine and Tennessee Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an
insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
Attention Maryland Residents: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or
benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
Attention New Jersey Residents: Any person who includes any false or misleading information on an application for an insurance policy
or knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
Attention New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall be subject to a civil
penalty not to exceed five thousand dollars and the stated value of the claim for each violation.
Attention North Carolina Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or
other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose
of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and subjects
such person to criminal and civil penalties.
Attention Ohio Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Attention Oklahoma Residents: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes
any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Attention Oregon Residents: Any person who with intent to injure, defraud, or deceive any insurance company or other person submits
an enrollment form for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto may have violated state law.
Attention Pennsylvania Residents: Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal
and civil penalties.
Attention Puerto Rico Residents: Any person who knowingly and with the intention to defraud includes false information in an
application for insurance or file, assist or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more
than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less
than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both.
If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are
present, the jail term may be reduced to a minimum of two (2) years.
Attention Texas Residents:
Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person
files an application for insurance or statement of claim containing any intentional misrepresentation of material fact or conceals, for the purpose
of misleading, information concerning any fact material thereto may commit a fraudulent insurance act, which may be a crime and may subject
such person to criminal and civil penalties.
Attention Vermont Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other
person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject
such person to criminal and civil penalties.
Attention Virginia Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other
person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent act, which is a crime and subjects such person to
criminal and civil penalties.
Attention Washington Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
GC-1564 (10-12) Page 2 of 2
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Completed 25 June 2020

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