Prescription Reimbursement Claim Form
Important!
»
Always allow up to 30 days from the time you receive the response to allow for mail time plus claims processing.
»
Keep a copy of all documents submitted for your records.
»
Do not staple or tape receipts or attachments to this form.
»
Reimbursement is not guaranteed and other contractor will review the claims subject to limitations, exclusions
and provisions of the plan.
STEP 1
Card Holder/Patient Information This section must be fully completed to ensure proper reimbursement of your claim.
Card Holder Information
Identication Number (refer to your prescription card) Group No./Group Name
Name (Last Name) (First Name)
Address
City State Zip
(MI)
Patient Information–Use a separate claim form for each patient.
Name (Last Name)
(First Name)
(MI)
Date of Birth Male Female Phone Number
Relationship to Primary member
Member
Spouse
Child
Other_______________
Other Insurance Information
COB (Coordination of Benets)
Are any of these medicines being taken for an on-the-job injury? Yes No
Is the medicine covered under any other group insurance? Yes No
If yes, is other coverage: Primary Secondary
If other coverage is Primary, include the explanation of benets (EOB) with this form.
Name of Insurance Company____________________________ ID#________________________
Important! A signature is REQUIRED
NOTICE
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
(Over)
Address 2
Country
14423-STANDARD-0814
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 • Medicine NDC number
• Date of Fill • Metric Quantity Total Charge
• Days Supply for your prescription (you need to ask your pharmacist for this “Day Supply” information)
• Pharmacy Name and Address or Pharmacy NABP Number
A valid Prescribing Physicians NPI (National Provider Identication) number is required, please provide: ____________
Prescribing physician’s information (all elds required):
Name:
___________________________________________________________________________
Address: __________________________________________________________________________
City, state, zip code: ________________________________ Phone number: ________________________
STEP 3
Mailing Instructions:
The RXBIN # is located on front of your
CVS/caremark Prescription ID card. Please
see highlighted area to the left for reference.
Match your RXBIN # to the addresses below.
RXBIN # 610415 mail to:
CVS/caremark
P.O. Box 52116
Phoenix, Arizona 85072-2116
IMPORTANT REMINDER–To avoid having to submit a paper claim form:
Always have your 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.
Additional Comments
RXBIN # 004336 , 012114 or if you are unable to locate your bin # mail to:
CVS/caremark
P.O. Box 52136
Phoenix, Arizona 85072-2136
RXBIN # 610029 mail to:
CVS/caremark
P.O. Box 52196
Phoenix, Arizona 85072-2196
Present this Prescription Card to ll your prescription at
any participating retail pharmacy.
For more information, visit www.caremark.com
or call a Customer Care representative toll-free at
1-877-347-7444.
Pharmacy Help Desk for Pharmacists: 1-800-364-6331
GLOBAL-IDCB-7444-0614
Submit paper claims to:
CVS/caremark Claims Department
P.O. Box 52136, Phoenix, AZ 85072-2136
00001
123456789
JOHN Q SAMPLE
ID
NAME
RxBIN 004336
RxPCN ADV
RxGRP RXTEST
Issuer (80840)
RxBIN 004336
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome