Steps for Submitting a Paper Claim Reimbursement Form

Reminders (NOTE – These may prevent you from having to submit a claim form)

• Use your ID card when obtaining prescriptions at a pharmacy.
• Use a network pharmacy.
• Fill prescriptions for drugs on your approved drug list/formulary.
• Claims will be processed within 30 business days.

How to Submit a Paper Claim Reimbursement Form for out-of-network pharmacies and Coordination of Benefits:

1. Review the Dos and Don'ts.
2. Download, print, and complete the Prescription Drug Claim Form.
3. Attach receipts.
4. Make copies of your submission and retain for records.
5. Mail to the address indicated on claim form.

Do’s:

• Complete the prescription claim reimbursement form that corresponds with the RXBIN number on your ID Card.
• NABP = National Association of Boards of Pharmacy number
• NDC = National Drug Code
• RXBIN = 004336
• Make a copy of prescription receipt and include with the claim form.
• If your plan has Coordination of Benefits (COB), you may submit a paper claim for consideration of your secondary benefit. Be sure to include primary claim payment information and EOB (explanation of benefits) to avoid delays in processing your claim.

Don’ts:

• Do Not include Mail Service Order Form with your paper claim submission.
• Do Not send in a cash register receipt.
• Do Not send medical or dental claims.

Contact Customer Care if you have any questions regarding your claim(s).

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