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Prescription drug reimbursement claim form

Prescription drug reimbursement claim form Instructions: Please read carefully or claims may be denied. Save time and money. In the future, present your blue cross blue shield of michigan ID card at a participating pharmacy and ask them to submit your Prescription claim electronically. We have over 50,000 pharmacies in our network . Submission Requirements Claims must be submitted within one year of the date of service. Claims over one year will not be reimbursed. Pharmacy receipts are required for each Prescription . o Cash register receipts are not accepted. o If you don't have a pharmacy receipt, ask your pharmacy to provide one to you. The following information is required to process your claim . o Refer to your pharmacy receipt or contact your pharmacy for missing information. Patient name and date of birth Prescribing physician name and NPI number Pharmacy name, address and telephone number Date of service Prescription number Name and strength of Prescription dispensed National drug Code (also referred to as NDC).

delay your reimbursement. Form instructions • •Complete this claim form if you paid full price for a prescription . and the pharmacy did not submit a claim to Blue Cross Blue Shield of Michigan and Blue Care Network, or if you are submitting a claim for coordination of benefits. • Complete a separate claim form for each patient and each

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Transcription of Prescription drug reimbursement claim form

1 Prescription drug reimbursement claim form Instructions: Please read carefully or claims may be denied. Save time and money. In the future, present your blue cross blue shield of michigan ID card at a participating pharmacy and ask them to submit your Prescription claim electronically. We have over 50,000 pharmacies in our network . Submission Requirements Claims must be submitted within one year of the date of service. Claims over one year will not be reimbursed. Pharmacy receipts are required for each Prescription . o Cash register receipts are not accepted. o If you don't have a pharmacy receipt, ask your pharmacy to provide one to you. The following information is required to process your claim . o Refer to your pharmacy receipt or contact your pharmacy for missing information. Patient name and date of birth Prescribing physician name and NPI number Pharmacy name, address and telephone number Date of service Prescription number Name and strength of Prescription dispensed National drug Code (also referred to as NDC).

2 Quantity Day supply Amount paid General Instructions 1. Complete this claim form if you paid full price for a Prescription and the pharmacy did not submit a claim to blue cross or if you are submitting for Coordination of Benefits. 2. Complete a separate claim form for each patient and for each prescribing physician and/or pharmacy used. 3. Include a pharmacy receipt for each Prescription submitted for reimbursement . 4. Read the acknowledgement carefully and sign and date the claim form . A signature is required to process your claim . 5. Return the completed claim form and pharmacy receipt(s) to: Express Scripts ATTN: Commercial Claims Box 14711. Lexington, KY 40512-4711. Or you may fax your claim form and pharmacy receipt(s) to: 608-741-5475. Please do not combine claims for different patients in the same fax submission.

3 ML6760D Express Scripts is an independent company that provides pharmacy services for blue cross blue shield of michigan . Prescription drug reimbursement claim form Foreign Prescriptions You may qualify for a vacation supply of your Prescription prior to traveling outside of the United States. For more information, call the Customer Service number located on the back of your blue cross blue shield of michigan ID card. Foreign Prescription Requirements Medication purchased outside of the United States must have an FDA approved American Equivalent to be considered for reimbursement . Medication purchased and shipped to you from a pharmacy outside of the United States will not be reimbursed. Claims must be submitted within one year of the date of service. Claims over one year will not be reimbursed.

4 Pharmacy receipts are required for each Prescription . The following information is required to process a foreign claim . Patient name and date of birth Pharmacy name, address and telephone number Date of service Name and strength of Prescription dispensed Quantity Day supply Amount paid Country Currency used Coordination of Benefits Instructions If blue cross blue shield of michigan is your secondary Prescription drug plan, complete the following steps for consideration of payment. 1. The claim must first be submitted to the primary Prescription drug plan for consideration of payment. 2. Once the primary plan has processed the claim , complete this claim form . 3. Provide your secondary blue cross group number and enrollee ID in the Cardholder Information section. 4. Check the box for Another health plan paid a portion in the Coordination of Benefits section.

5 5. Attach the Explanation of Benefits (EOB) statement from the primary plan. The EOB statement should clearly indicate the cost of the Prescription and what was paid by the primary plan. If the primary plan didn't provide an EOB statement, attach the pharmacy receipt. An EOB or pharmacy receipt is required to process your claim . Express Scripts is an independent company that provides pharmacy services for blue cross blue shield of michigan . 3 UHVFULSWLRQ 'UXJ 5 HLPEXUVHPHQW &ODLP )RUP. &RPSOHWH WKH IURQW DQG EDFN RI WKH FODLP IRUP DQG LQFOXGH S KDUPDF\ UHFHLSWV . BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB. &ODLPV PD\ EH GHQLHG LI LQFRPSOHWH B BBBBBBBBBBBBBBB. &DUGKROGHU ,QIRUPDWLRQ UHIHU WR \RXU %OXH &URVV ,' FDUG 3 KDUPDF\ UHFHLSWV DUH UHTXLUHG IRU DOO FODLPV . 6HH EDFN RI WKH FODLP IRUP IRU GHWDLOV . &KHFN \RXU 5[*US % %&%60$1.]

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