MAPD PRESCRIPTION REIMBURSEMENT REQUEST FORM

Reimbursement is not guaranteed. Claims are subject to your plan s limits exclusions and provisions. Include EACH ingredient used in the compound prescription. For each NDC number indicate the metric quantity expressed in the number of tablets grams milliliters creams ointments injectables etc. Filled Rx VALID 11 digit NDC Days Supply Ingredient Cost Indicate the TOTAL amount paid by the patient. Receipt s must be provided with this claim form. I ndividual quantities must equal the total quantity. Section A Pharmacy Receipt s for Reimbursement Use the following checklist to ensure your receipt s have all information required for your reimbursement request Date prescription filled National Drug Code NDC number Prescription number Rx number Name and address of pharmacy Name of drug and strength Quantity Section B Compound Information for compound prescriptions ONLY Pharmacist must complete and sign List VALID 11 digit NDC number highest to lowest cost in the box at right. Include EACH ingredient used in the compound prescription. For each NDC number indicate the metric quantity expressed in the number of tablets grams milliliters creams ointments injectables etc. Filled Rx VALID 11 digit NDC Days Supply Ingredient Cost Indicate the TOTAL amount paid by the patient. No EOB is needed. Just complete this form and submit the pharmacy receipt s showing the amount you paid at the pharmacy. Receipt s must be provided with this claim form. I ndividual quantities must equal the total quantity. Individual ingredient costs plus compounding fees must be equal to the total ingredient costs. X Compounding Fee Signature of Pharmacist Total Section C Coordination of Benefits You must submit claims within 36 months of date of purchase or as required by your plan. When submitting an Explanation of Benefits EOB from another health plan or Medicare If you have not already done so submit the claim to the primary plan or Medicare. State ZIP Date of Birth mm/dd/yyyy Gender M F Physician and Pharmacy Information Prescribing Physician Name Dispensing Pharmacy Name Reason for Request Select appropriate options for your request I did not use my prescription drug ID card. I used a non-participating pharmacy for one of the following reasons I traveled outside my plan s service area and needed my medication but could not access a network pharmacy. Individual ingredient costs plus compounding fees must be equal to the total ingredient costs. X Compounding Fee Signature of Pharmacist Total Section C Coordination of Benefits You must submit claims within 36 months of date of purchase or as required by your plan. When submitting an Explanation of Benefits EOB from another health plan or Medicare If you have not already done so submit the claim to the primary plan or Medicare. Once you receive the EOB complete this form submit the pharmacy receipt s and attach the EOB. The EOB must clearly indicate the cost of the prescription and amount paid by the primary plan or Medicare. I also certify that the claim s being submitted for payment are not eligible for payment under a no-fault automobile or worker s compensation insurance program. I also authorize release of all information pertaining to this claim s to the plan administrator underwriter sponsored policy holder and/or employer. X Member or Authorized Representative Signature Date NOTE If form is completed and signed by an Authorized Representative rather than the member an Authorization of Representation AOR must accompany the request or Power of Attorney POA must be on file with the plan. ORX5262-UHCMRM140129 SSCFOR5262UHCMRM Instructions for Submitting Form 1.