Prescription Drug Claim Reimbursement Form

  • Each Pharmacy Receipt Must Show:
    • Participant Name
    • Prescription Number
    • Pharmacy Name and Address or NABP Number
    • Name/Strength and NDC Number
    • Metric Quantity/Days Supply
    • Dispense as written(DAW), if applicable
    • Purchase Date
    • Total Charge

    The submission of this claim form, for you or any of your dependents, authorizes the release of all information to applicable health care providers and all others involved in filling the prescription or processing the claims submitted.

  • PLEASE COMPLETE SECTIONS 1 THROUGH 4. INCLUDE RECEIPTS BEFORE MAILING

    Please use a separate claim form for each covered member of the family.
  • 1. SUBSCRIBER INFORMATION

  • 2. PARTICIPANT INFORMATION

  • Date Format: MM slash DD slash YYYY
  • Coordination of Benefits

  • If other coverage is Primary, include the explanation of benefits (EOB) with this form.

  • 3. REASON FOR CLAIM OR SPECIAL NOTES

  • FRAUD PREVENTION REGULATION: Any person who knowingly and with intent to defraud any insurance company or other person flies an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material there to commits a fraudulent insurance act. which is a crime and subjects such person to criminal and civil penalties.
  • RELEASE OF INFORMATION: I certify that I (or my eligible dependent) have received the medicine described here in and that the plan participant named is eligible for prescription benefits. I also certify that the medicine received is not for treatment of an on-the-job injury. I have indicated in the COB box above if there is primary prescription drug coverage under another medical plan. I authorize release of all information pertaining to this claim to TruScripts., the prescription benefit manager; insurance underwriter; sponsor; policyholder; and /or employer. I certify that all the information entered on this form is correct.
  • Date Format: MM slash DD slash YYYY
  • Drop files here or