UNBRANDED PPC 006 Prescription Drug Claim Form OH Japanese Language Update 07 02 WUE1500 Pw 014849

User Manual: WUE1500

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Page Count: 2

Prescription Drug Claim Form
A. - Cardholder / Patient Informatio
n
M F Sel
f
Spous
e
Child Othe
r
Is the patient eligible for Medicare, Part D (prescription drug) coverag
e
No Ye
s
B. - Other Insurance Coverage
No Ye
s
I
f
yes , please use other insurance card to complete the
f
ollowing
f
iel
d
Signature Date
1.
No Yes
No Yes
2.
No Yes
No Yes
3.
No Yes
Complete all sections ONLY if the original pharmacy prescription receipts are not being submitted with this form. Receipt copies will not be accepted.
D. - Claim Information (Completed by pharmacist/physician)
Is this a compound Rx? If Yes , please attach
a Compound Claim form. Fill Date Rx Number Quantity Days Supply Strength/Dosage
Rx Number Strength/DosageQuantity
National Drug Code (NDC) Medication Name (U.S. English Charge (U.S. Dollars)
Charge (U.S. Dollars)
Was this prescription filled in a foreign country? Name of Country Currency
Is this a compound Rx? If Yes , please attach
a Compound Claim form. Fill Date
National Drug Code (NDC) Medication Name (U.S. English
Is this a compound Rx? If Yes , please attach
a Compound Claim form. Strength/Dosage
ZIP
Patient's Gende
Is the patient eligible for primary prescription drug coverage from another provid
e
Insured's Name (Last, First, MI
)
Today's Date
Cardholder's Name (Last, First, MI
A
ddress Cit
y
Stat
e
State
National Provider Indicator (NPI) numbe
Days Supply
Address
QuantityFill Date Rx Number
ZIP
Prescriber ID
Days Supply
Prescriber Name
Prescriber ID
Foreign Medication Name
Prescriber Name
Foreign Charge
Pharmacist / Physician Signature
CityPharmacist / Physician Name
I certify that the information on this claim form is correct to the best of my knowledge. I authorize the release of any medical information pertaining to
this claim to Express Scripts, its agents or representatives.
C. - Authorization (Completed by pharmacist / physician)
Pharmacy Name
Cardholder ID Numbe
r
Patient's Date of Birt
h
Patient's Name (Last, First, MI
Why was the insurance or drug card not used for this purchase? Explain belo
w
Plan Nam
e
Patient's Relationship to Cardhold
e
Other Insurance Company's Name Member ID PCN Other Coverage's Effective Date
Note: Payment for the above claim(s) will be made directly to the
Policyholder. Any assignment of these benefits must include the
signature of the Policyholder and is subject to approval of your
prescription drug plan administrator.
Was this prescription filled in a foreign country? Name of Country Currency Foreign Medication Name Foreign Charge
Express Scripts, Inc., is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan
members.
PPC 006 100101
No Ye
s
4.
No Ye
s
No Ye
s
Insurance Fraud Warnin
g
Cardholde
r
1.
2.
3.
5.
6.
7. Mail completed form to:
양식에 관한 문의사항이 있으시면 귀하의 ID카드 뒷면 또는 등록 책자에 있는 전화번로
전화하셔서 고객 서비스 상담원에게 문의하여 주십시오.
如果你对此表格持有任何疑问,请致电您所持会员卡背后的或者是注册簿上的电话号码,以联系我
们的客服代表。
Japanese: 日本語:この書類についてご不明な点は、お客様のIDードの裏面または保険加入用冊子に記
載された電話番号にお電話いただいた上、お客様サービス担当係にお問い合わせください。
Prescriber Nam
e
Prescriber I
D
Vietnamese:
4. Include the ORIGINAL prescription receipt with this form and make copies for your records. Copies of the receipt will not be accepted for reimbursement.
If you have any questions regarding this form, please contact one of our customer service representatives by
calling the number on the back of your ID card or in your enrollment booklet.
Tagalog: Kung mayroon kang mga katanungan may kinalaman sa form na ito, mangyaring makipag-ugnayan sa isa sa
aming mga customer service representative sa pamamagitan ng pagtawag sa numero na nasa likod ng iyong ID
card o sa iyong booklet sa pagpapatala.
If original pharmacy receipts are being submitted with this form, please go to step 7. If not, continue to step 6.
If original pharmacy receipts are NOT submitted with the form, please have your pharmacist complete sections (C) and (D) on page 2.
Korean:
Chinese:
National Drug Code (NDC
)
Medication Name (U.S. English Charge (U.S. Dollars
)
Nếu quý v có bt k câu hi gì liên quan đến mu đơ n này, xin vui lòng liên h vi mt trong nhng đại din dc
h
v khách hàng ca chúng tôi bng cách gi s đin thoi sau th ID ca quý v hay cun s tuyn dng.
Spanish: Si tiene alguna pregunta respecto a este formulario, por favor, comuníquese con nuestros representantes de
servicio al cliente llamando al número que se encuentra al reverso de su tarjeta de identificación o en su folleto
de inscripción.
English:
Prescription Drug Plan - PO Box 145433 - Cincinnati, OH 45250-5433
Present your prescription drug card at the pharmacy to avoid having to submit a paper claim for reimbursement. If necessary, use this form for prescription
claims that were purchased due to an emergency or at a non-participating pharmacy.
Complete all items in the section (A) and (B) for both cardholder and patient.
Sign the form in the area provided.
Was this prescription filled in a foreign country? Name of Countr
y
Currenc
y
Foreign Medication Nam
e
National Drug Code (NDC
)
Medication Name (U.S. English Charge (U.S. Dollars
)
Prescriber Nam
e
Foreign Charg
e
Prescriber I
D
Was this prescription filled in a foreign country? Name of Countr
y
Currenc
y
Foreign Medication Nam
e
Quantit
y
Da
y
s Su
pp
l
y
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to
defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance
company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to
defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the appropriate state agency within the
department of regulatory agencies.
Stren
g
th/Dosa
ge
INSTRUCTIONS
Is this a compound Rx? If Yes , please attach
a Compound Claim form. Fill Dat
e
Rx Numbe
r
Foreign Charg
e
Express Scripts, Inc., is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan
members.
PPC 006 100101

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