Prescription Reimbursement Claim Form
Important!
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Always allow up to 30 days from the time you receive the response to allow for mail time plus claims processing.
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Keep a copy of all documents submitted for your records.
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Do not staple or tape receipts or attachments to this form.
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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
Identication 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 Benets)
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 benets (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 benets, 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
