Fillable Prescription Drug Reimbursement Form Information and Instructions (Blue Shield of California)

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Prescription Drug Reimbursement Form Information and Instructions (Blue Shield of California)

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The Prescription Drug Reimbursement Form Information and Instructions (Blue Shield of California) form is 2 pages long and contains:

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  • 11 check-boxes
  • 22 other fields

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File type: PDF

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Blue Shield of California
50 Beale Street, San Francisco, CA 94105
blueshieldca.com
Prescription Drug Reimbursement Form Information and Instructions
General Information
1. If you are a Medicare Part D subscriber, do not complete this form. Instead, visit our website:
https://blueshieldca.com/medicare, select plans with drug coverage then select exceptions and appeals to
download a “Coverage Determination Form,” OR contact your member service number, which is located
on your ID card.
2. To avoid undue delay, complete all required areas of information on the claim form.
3. Be sure to include your subscriber identification number (ID#) exactly as it appears on the Blue Shield
identification card. If this is not done, the reimbursement form will be returned to you.
4. Keep a copy of your receipt(s) for your records.
Instructions - How to complete this form
Part One
1. Copy the Subscriber Identification
Number on the Blue Shield ID card.
2. Subscriber name, address, and
telephone number.
3. Patient Name: Person for whom the
drug was prescribed.
4. Patient Date of Birth: Month, Day,
Year.
5. Patient Sex: Check Male or Female.
6. Status: Patient’s relationship to
subscriber. If other, please write in
type of relationship.
7. Please use separate claim form for each
family member.
Part Two
1. Pharmacy name, address, and telephone number where the
prescription(s) were purchased.
2. Pharmacy ID (NCPDP/NPI): Obtain this number from the
pharmacy where prescriptions were purchased.
3. Tape a copy of pharmacy label receipts (not the register receipt for
payment) to the form in the space provided. The receipts must
indicate date of service, Rx number, NDC number, quantity, days
supply and the amount paid. For foreign claims, state the currency
used.
4. For medications compounded by the pharmacy, the pharmacist must
complete and sign the sections titled, “medications compounded
by pharmacy” and “compounded medications” on page one of
this form.
5. Use a separate claim form for each pharmacy from which you
have purchased prescriptions.
Note: Claim submission is not a guarantee of payment.
Reason for Claim Submission:
Your Blue Shield ID Card was missing when you purchased your
medication.
You did not use a pharmacy in the Blue Shield Pharmacy Network.
Prior Authorization was approved after you purchased your
medication.
The pharmacy was unable to process your prescription online due
to system unavailability.
Your medication was compounded especially for you by your
pharmacy.
You obtained more medications than your plan covers because
you required a vacation supply.
Other Reason: ___________________________________________
Submit to:
By Mail:
Blue Shield
c/o Pharmacy Services
PO BOX 7168
San Francisco, CA 94120-7168
-or-
By Fax:
1(888) 697-8122
Foreign Claims:
Include your prescription receipt with the name of the drug(s) and
state the foreign currency used.
Submit to:
By Mail:
Blue Shield of California
Attn: Foreign Claims
PO BOX 272550
Chico, CA 95927-2550
Blue Shield of California
50 Beale Street, San Francisco, CA 94105
blueshieldca.com
Prescription Drug Reimbursement Form for University of California Members
If you are a Medicare Part D subscriber, do not complete this form. Instead, visit our website:
https://blueshieldca.com/medicare, select plans with drug coverage then select exceptions and appeals to download a
“Coverage Determination Form,” OR contact your member service number, which is located on your ID card.
Part One: Member Information - To Be Filled Out By You
SUSCRIBER IDENTIFICATION NUMBER
SUSCRIBER NAME
DAYTIME TELEPHONE
MAIL ADDRESS - STREET
PATIENT’S NAME
PATIENT’S DATE OF BIRTH (MM/DD/YY)
SEX: MALE FEMALE
RELATIONSHIP:
SUSCRIBER SPOUSE CHILD
OTHER: ___________________________
EXPLAINE RELATIONSHIP
The undersigned certifies that the medication(s)
described herein was received by the undersigned for
the party(s) named below who is/are eligible for drug
benefits, and that such medication(s) is/are not for an
on the job injury or covered under another benefit
plan. The undersigned authorizes release of all
information to the plan administrator, underwriter,
sponsor, policy holder, employer and their agents for
use in connection with the benefit plan programs.
Information may also be used for other reporting and
analysis purposes without identification of the
undersigned or the undersigned’s family members.
The undersigned further authorizes use of such
person’s subscriber identification number for
identification purposes and further recognizes that
reimbursement will be paid directly to the participant
and assignment of these benefits to a pharmacy or
otherwise is void.
SIGNATURE OF PATIENT, GUARDIAN OR LEGAL
REPRESENTATIVE
CITY STATE ZIP
Part Two: Pharmacy Information - To Be Filled Out By You or Your Pharmacist
PHARMACY NAME ADDRESS - STREET PHARMACY ID (NCPDP/NPI)
CITY STATE ZIP PHARMACY TELEPHONE
Compounded Medications: Pharmacist to identify the specific
medications by date of service and Rx number. Please list name,
NDC# and metric quantities of each ingredient in box on left.
Signature of Pharmacist for Compounded Medications
X
X
Medications compounded by Pharmacy
Medication #2
Medication #1
TAPE PHARMACY LABEL RECEIPT
TAPE PHARMACY LABEL RECEIPT
Medication #3
Medication #4
TAPE PHARMACY LABEL RECEIPT
TAPE PHARMACY LABEL RECEIPT
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Prescription Drug Reimbursement Form Information and Instructions (Blue Shield of California)

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Completed 11 March 2021

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