PHARMACY SERVICES PRESCRIPTION DRUG CLAIM FORM INSTRUCTIONS PLEASE PRINT ALL SECTIONS 1. This form is to be used to seek reimbursement from EmblemHealth for prescription drug costs you
PHARMACY SERVICES PRESCRIPTION DRUG CLAIM FORM INSTRUCTIONS PLEASE PRINT ALL SECTIONS 1. This form is to be used to seek reimbursement from EmblemHealth for prescription drug costs you paid above the cost-share amounts outlined under your plan's prescription drug benefits. 2. Complete all sections. We need all the information requested to process your claims. 3. Have your pharmacist complete sections C, D1, D2, and D3. Receipts must be attached. 4. Use a separate form for each subscriber/patient. Use a separate form for each pharmacy serving the patient. 5. Send this form by mail or fax to: Express Scripts: Attn: Medicare Part D Address: P.O. Box 14718 Lexington, KY 40512-4718 Fax Number: 608-741-5483 6. If you have over-the-counter benefits (which includes coverage for analgesics, proton pump inhibitors, cough/cold medicines, or antacids), attach your itemized receipts and return. You do not need to complete Section C. If you have questions, call EmblemHealth at 877-444-7097 (TTY: 711), 8 am to 8 pm, seven days a week. A representative is happy to help. A. SUBSCRIBER INFORMATION FOR OFFICE USE ID # Claim # Subscriber's Name (Last) (First) (MI) Street Address City State ZIP SUBSCRIBER SIGNATURE: B. PATIENT INFORMATION Patient's Name (Last) (First) (MI) Date of Birth / / Male Female Patient's ID # Patient's relationship to insured: Self Spouse Dependent I certify that all subscriber and patient information is correct and the medication has been dispensed. I authorize release of any information relating to this claim to EmblemHealth and all necessary third partiesfor purposesofclaims investigationandpayment,utilization review,and audit. PATIENT'S SIGNATURE: Y0026_201900_C C. PHARMACY INFORMATION NABP # Pharmacy Street Address Telephone # City PHARMACIST'S SIGNATURE: Pharmacy Name State ZIP D1 PRESCRIPTION INFORMATION Date Dispensed Name of Medication NDC # New Refill Qty Dispensed Strength Prescriber's Name Rx # Days Supply Prescription Cost $ , . Prescriber's State License # D2 PRESCRIPTION INFORMATION Date Dispensed Name of Medication NDC # New Refill Qty Dispensed Strength Prescriber's Name Rx # Days Supply Prescription Cost $ , . Prescriber's State License # D3 PRESCRIPTION INFORMATION Date Dispensed Name of Medication NDC # New Refill Qty Dispensed Strength Prescriber's Name Rx # Days Supply Prescription Cost $ , . Prescriber's State License # The formulary and pharmacy network may change at any time. You will receive notice when necessary. Y0026_201900_CMicrosoft Word 2010