Fillable Medicare Part D: Prescription Claim Form Important! (John Hopkins Medicine Medicare Plan)

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Medicare Part D: Prescription Claim Form Important! (John Hopkins Medicine Medicare Plan)

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The Medicare Part D: Prescription Claim Form Important! (John Hopkins Medicine Medicare Plan) form is 2 pages long and contains:

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  • 26 check-boxes
  • 44 other fields

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File type: PDF

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Medicare Part D: Prescription Claim Form
Important!
Mail completed forms with receiptsUP:
$74$BSFNBSL.FEJDBSF1BSU%$MBJNT1SPDFTTJOH
P.O. Box 526
Phoenix, Arizona 85072-26
• Your complete claim will be processed within 14 days of
receipt of your request. Please allow additional mail time.
• Keep a copy of all documents submitted for your records.
• Do not staple or tape receipts or attachments to this form.
STEP 1
Patient Information This section must be fully completed to ensure proper reimbursement of your claim.
Patient Information
Identication Number (refer to your prescription card) Group No./Group Name
Name (Last Name) (First Name) (MI)
Address
Address 2
City State Zip
Date of Birth Male Female Phone Number
X
Tell us about your prescriptions
WERE ANY PRESCRIPTIONS: WERE ANY PRESCRIPTIONS:
Covered by a manufacturer patient
assistance program? YES NO
Covered under another plan
(e.g., through an employer)? YES NO
If yes, is this other plan Primary? YES NO
If Primary, include the explanation of benefits (EOB) with
your submission and let us know:
Name of Insurance Company:
__________________________________________
ID Number: ________________________________
Approved for a drug tier cost change? YES NO
A compound prescription? YES NO
From an outpatient hospital observation stay? YES NO
From a long-term care pharmacy? YES NO
Filled as a result of:
• Illness after travelling outside of the service area? YES NO
• No network pharmacy within reasonable
driving distance? YES NO
• Medication not in stock at my network pharmacy? YES NO
• Vaccine received at my doctor’s oce? YES NO
• Federal emergency/natural disaster? YES NO
Other reasons can be provided in Step 3, page 2.
(Over)
For Compound Prescriptions, please click here or use the attached form, for Vaccines: please click here or use the attached form.
Important! A signature is REQUIRED
Any person who knowingly and with intent to defraud, injure, or deceive any insurance company, submits a claim or application containing any
materially false, deceptive, incomplete or misleading information pertaining to such claim may be committing a fraudulent insurance act which is a
crime and may subject such person to criminal or civil penalties, including nes, denial of benets, and/or imprisonment.
I certify that I (or my eligible dependent) have received the medicine described herein. I certify that I have read and understood this form, and that all
the information entered on this form is true and correct.
Signature of Plan Participant
Date
Please note: If completing this form on behalf of a Medicare Part D member, please submit a completed CMS 1696 form (Appointment of Representative form).
Per CMS regulations, a purported representative may submit a completed a CMS 1696 form or a form that includes the same information as a 1696 form.
click to sign
signature
click to edit
STEP 2
Submission Requirements:
You MUST include all original “pharmacy” receipts in order for your claim to process. “Cash register” receipts will only be accepted for
diabetic supplies. The minimum information that must be included on your pharmacy receipts is listed below:
• Patient Name • Prescription Number • Drug’s 11 Digit NDC Number • Date of Fill • Quantity of Drug • Total Paid
• Days Supply for your prescription (you need to ask your pharmacist for this “Day Supply” information)
Pharmacy name and address or pharmacy NABP number: ___________________________________________________
Prescribing physician’s name: _____________________________________________________________________
Prescribing physician’s address: ____________________________________________________________________
Prescribing physician’s phone number: _______________________________________________________________
Number of prescriptions you are submitting for reimbursement: ____________________________
rescription 1P
Prescription (Rx) Number
Drug Name
National Drug Code (NDC Number)
Date Filled (MM/DD/YY) Total Paid ($ Amount)
Prescriber’s National Provider Identier Number Quantity of Drug Days Supply
rescription 2P
Prescription (Rx) Number
Drug Name
National Drug Code (NDC Number)
Date Filled (MM/DD/YY) Total Paid ($ Amount)
Prescriber’s National Provider Identier Number Quantity of Drug Days Supply
rescription 3P
Prescription (Rx) Number
Drug Name
National Drug Code (NDC Number)
Date Filled (MM/DD/YY) Total Paid ($ Amount)
Prescriber’s National Provider Identier Number Quantity of Drug Days Supply
Please utilize Additional Prescription Information page if necessary (more than 3 prescriptions).
STEP 3
Provide any Additional Comments or Information Here:
Please remember that completing this form is not a guarantee that you’ll be reimbursed.
IMPORTANT REMINDER–To avoid having to submit a paper claim form:
• Always have your prescription card available at time of purchase.
• Use medication from your formulary list.
• Always use pharmacies within your network.
• If problems are encountered at the pharmacy, call the number on the back of your card.
Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.
" 062620
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Medicare Part D: Prescription Claim Form Important (John Hopkins Medicine Medicare Plan)

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Completed 25 May 2021

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