Fillable Medicaid Prescription Claim Reimbursement Form

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Medicaid Prescription Claim Reimbursement Form

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The Medicaid Prescription Claim Reimbursement Form form is 2 pages long and contains:

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Medicaid Prescription Claim
Reimbursement Form
For claim reimbursement, complete this form and mail to:
Envolve Pharmacy Solutions
P.O. Box 989000
West Sacramento, CA 95798
Incomplete forms will delay processing. Envolve Pharmacy Solutions Customer Service can be reached
at (800) 460-8988.
Important!
It is our intent to process the claims within 60 days
Keep a copy of all documents submitted for your records
Reimbursement is not guaranteed; claims are subject to plan limitations, exclusions and provisions
To be completed by insured. Please PRINT clearly.
I. MEMBER AND PRESCRIPTION PLAN INFORMATION
Member Name: Member ID #:
Address: Phone:
City, State, Zip Code: Group #:
Gender: ⧠
M ⧠ F
Birth Date: /_____
__ /________
Plan Name:
Relationship to Insured:
⧠ Self ⧠ Spouse ⧠ Dependent ⧠ Other: _ _______________________________________________
Coordination of Benefits (COB)
Is the medicine covered under any other group insurance? ⧠ Yes ⧠ No
*If other coverage is Primary, include the Explanation of Benefits (EOB) with this form.
Explanation for the request.
(Continued on the back)
II. PRESCRIPTION INFORMATION
This section must be completed by you or your dispensing pharmacist. One prescription label
should be attached for each prescription.
Also, include a copy of your pharmacy receipt with this form.
Pharmacy Name: Pharmacy Address:
RX Number:
Date Filled: ___
/____ /________
Quantity:
RX Name & Strength: Days Supply (30, 60, 90): NDC #:
____________-___________-______
Dr. Name: Price/Amount Paid: Comments:
Pharmacy Name: Pharmacy Address:
RX Number:
Date Filled: ___ /____ /________
Quantity:
RX Name & Strength: Days Supply (30, 60, 90): NDC #:
____________-___________-______
Dr. Name: Price: Comments:
Important! A signature is required.
Please sign and date here: I certify that the above information is correct and the prescriptions listed
above are for myself or eligible members of my family who have received the medication described
above, and I authorize release of all information contained on this claim form to Envolve Pharmacy
Solutions and my plan sponsor.
Signature: _________________________________________________________________________ Date signed: _ ___________________________
Rev. 1120
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Medicaid Prescription Claim Reimbursement Form

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Completed 24 February 2022

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