Fillable Medicare Part D: Prescription Claim Form Important!

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Medicare Part D: Prescription Claim Form Important!

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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)
Address
City State Zip
(MI)
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
X
Address 2
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.
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.
Date of Birth Male Female Phone Number
(Over)
For Compound Prescriptions, please click here or use the attached form, for Vaccines: please click here or use the attached form.
Mail completed forms with receipts to
:
CVS Caremark Medicare Part D Claims Processing
P.O. Box 52066
Phoenix, Arizona 85072-2066
Medicare Part D: Prescription Claim Form
Important!
• 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.
•
•
Submission Requirements:
IMPORTANT REMINDER–To avoid having to submit a paper claim form:
• Always have your prescription card available at time of purchase.
• Always use pharmacies within your network.
• Use medication from your formulary list.
• If problems are encountered at the pharmacy, call the number on the back of your card.
STEP 2
Number of prescriptions you are submitting for reimbursement: ____________________________
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: _______________________________________________________________
Please utilize Additional Prescription Information page if necessary (more than 3 prescriptions).
Please remember that completing this form is not a guarantee that you’ll be reimbursed.
Provide any Additional Comments or Information Here:
STEP 3
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
Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.
5246-1108394A1 062620
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Medicare Part D: Prescription Claim Form Important

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Completed 6 January 2022

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