Card Holder Information Identification Number (refer to your prescription card) Other Insurance Information

Transcription

1 14423-STANDARD-0514 PrescriptionReimbursement Claim Form Important! * Always allow up to 30 days from the time you receive the response to allow for mail time plus claims processing. * Keep a copy of all documents submitted for your records. * Do not staple or tape receipts or attachments to this form. * Reimbursement is not guaranteed and other contractor will review the claims subject to limitations, exclusions and provisions of the plan. Card Holder Information Identification Number (refer to your prescription card) Group No./Group Name Name (Last Name) (First Name) (MI) Address Address2 City State Zip Country Name (Last Name) (First Name) (MI) Date of Birth Male Female PhoneNumber Relationship to Primary member Member Spouse Child Other Insurance Information Other Important! Asignatureis REQUIRED NOTICE Anypersonwhoknowinglyandwithintenttodefraud,injure,ordeceiveanyinsurancecompany,submitsa claim orapplicationcontaining anymateriallyfalse,deceptive,incompleteormisleadinginformationpertaining tosuch claim may be committinga fraudulentinsurance act which is a crime and may subject such person to criminal or civil penalties, including fines, denial of benefits, and/or imprisonment. I certify thati (or my eligible dependent) havereceivedthe medicine described herein.i certify thati have read and understood this form, andthatalltheinformationenteredonthisformistrueandcorrect. X

2 Signature of Plan Participant Date (Over)

3 You MUST include all original pharmacy receipts in order for your claim to process. Cash register receipts will only be accepted for diabetic supplies. The minimum information that must be included on your pharmacy receipts is listed below: Patient Name PrescriptionNumber Medicine NDC number DateofFill MetricQuantity Total Charge Days Supply for your prescription (you need to ask your pharmacist for this Day Supply information) Pharmacy Name and Address or Pharmacy NABP Number A valid Prescribing Physician s NPI (National Provider Identification) number is required, please provide: Prescribing physician s information (all fields required): Name: Address: City, state, zip code: Phone number: Additional Comments RxPCN Issuer (80840) ID The RXBIN # is located on front of your PrescriptionID card.please see highlighted area to the left for reference. Match your RXBIN # to the addresses below. RXBIN # mail to: RXBIN # , or if you are unable to locate your bin # mail to: RXBIN#610029mailto: RXBIN # , , or mail to: RXBIN # , mail to: To avoid having to submit a paper claim form: P.O. Box Phoenix, Arizona P.O. Box Phoenix, Arizona P.O. Box Phoenix, Arizona P.O. Box Phoenix, Arizona P.O. Box Phoenix, Arizona IMPORTANT REMINDER Alwayshaveyourcardavailableattimeofpurchase. Always use pharmacies within your network. Use medication from your formulary list. Ifproblemsareencounteredatthepharmacy,callthenumberonthebackofyourcard STANDARD-0514

4 NON-DISCRIMINATION AND LANGUAGE ASSISTANCE NOTICE NOTICE: Our Company complies with applicable federal and state civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, disability, or sex. We provide free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, written information in various formats (large print, audio, accessible electronic formats, other formats), and language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact our Civil Rights Coordinator. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator 601 Gaines Street, Little Rock, AR Phone: ; TDD: You can file a grievance in person, by mail, or by . If you need help filing a grievance our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC Phone: ; TDD: Complaint forms are available at ATTENTION: Language assistance services, free of charge, are available to you. Call ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 번으로전화해주십시오. NOTICE

5 ǟ Ɠ PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните مجانا. دعوة الغدد. ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele مالحظة: إذا كنت تتحدث الغربية تتوفر لϙ خدمات المساعدة المغوية ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le UWAGA: Jeżeli mòwisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます まで お電話にてご連絡ください ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: مالحظة: إذا كنت تتحدث بالمغة القارسية والخدمات المغوية المϘدمة مجانا بالنسبة لϙ. يرجى االتص لا સk ચન : જ તમ ગજર તj k બ લત હ, ત ન:શલ ક k ભ ષ સહ ય સવ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર ध य न द : यदद आप ह द ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलफ ध ह पर क ल कर LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau انتببہ : آپ اردو بولتے ہيں تو زبان کی مدد کی خدمات ببل مغاوضہ دستياب مقت ہيں. ک لا کريں ťňłŀřņ: ŃŘŐŘ Ǜ Ɠ ńřņţőřŋřőř Ɠ ƑǛ ŏřő, ĺřņņƌ ŏĺřņŀőŀţœœłřņŋřőř, Ǝƒ Ǜ ťłŀņ ǟ Ɠ ţőǡļř, Ɗ Ɠ ŤŌŅŌ Ɠ ƌ ŊǛ œōŧœǜ ńɠ ŘŅ. ťńŏ LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk wōṇāān. Kaalọk NOTICE