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 Identication) number is required, please provide:
Prescribing physician’s information (all elds required):
City, state, zip: ___________________________________________________________________________________
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.
P.O. Box 52136
Phoenix, Arizona 85072-2136
Signature of Pharmacist or Representative (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 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 (REQUIRED) Date
Important! A signature is REQUIRED
Pharmacy Information Continued
Phone Number Is this an on-site nursing home pharmacy?
NCPDP/NPI RequiredYES NO