Fillable Prescription Reimbursement Claim Form Important! (UnitedAg)

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Prescription Reimbursement Claim Form Important! (UnitedAg)

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Prescription Reimbursement Claim Form
Important!
STEP 1
Card Holder/Patient Information
This section must be fully completed to ensure proper reimbursement of your claim.
Card Holder Information
Patient Information–Use a separate claim form for each patient
Pharmacy Information
Identication Number (refer to your prescription card)
Group Number/Group Name
Last Name
First Name
MI
Address
Address 2
City
State Zip Country
Date of Birth Male Female Phone Number
Relationship to Primary Member
Member
Spouse
Child
Other
14423-STANDARD-0816
• 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 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.
REQUIRED: Please check appropriate
box for submitting a paper claim. Claim will
be returned if incomplete. (tape receipts or
itemized bills on the back)
Reason I am ling this form is:
q Out of the country
q Pharmacy does not accept insurance
q Compound
q No insurance coverage at the time
q Other–provide reason below
_____________________________
_____________________________
q Medication purchased outside of the
United States (tape receipts or itemized bills
on the back)
PLEASE INDICATE:
Country:
_______________________
Currency used: ___________________
Last Name
First Name
MI
___________________________________________
Pharmacy Name
Address
City
State Zip
Other Insurance Information
Coordination of Benets (COB)
Are any of these medicines being taken for
an on-the-job injury?
q YES q NO
Is the medicine covered under any other
group insurance?
q YES q NO
If YES, is other coverage:
q PRIMARY q SECONDARY
q MEDICARE PART D
If other coverage is PRIMARY, include
the Explanation of Benets (EOB) with
this form.
Name of Insurance Company:
_____________________________
_____________________________
ID#:
__________________________
Continued
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 Physician’s NPI (National Provider Identication) number is required, please provide:
___________________________
Prescribing physician’s information (all elds required):
Name: ________________________________________________________________________________________
Address: _______________________________________________________________________________________
City, state, zip: ___________________________________________________________________________________
Phone: ________________________________________________________________________________________
Additional comments: ______________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Mail completed forms with receipts to:
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.
CVS Caremark
P.O. Box 52136
Phoenix, Arizona 85072-2136
Signature of Pharmacist or Representative (REQUIRED)
X
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 (REQUIRED) Date
X
Important! A signature is REQUIRED
Pharmacy Information Continued
Phone Number Is this an on-site nursing home pharmacy?
NCPDP/NPI RequiredYES NO
STEP 2
STEP 3
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Prescription Reimbursement Claim Form Important (UnitedAg)

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Completed 20 May 2021

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