Prescription Drug Claim Form

2017-0620W Prescription Drug Claim Form Direct Member Reimbursement This claim form can be used to request reimbursement of covered expenses. Please check which reason applies. Alert: If your claim was processed by the pharmacy using insurance or a discount card. A discount card is not insurance. Your plan may consider that claim fully paid. Additional reimbursement might not be provided. I did not have my ID card at the time of purchase I was charged for medication received during an Urgent/Emergent Visit I was administered a Medicare Part D covered vaccine in my doctor’s office Primary coverage is with another insurance carrier. (Coordination of Benefits) Additional Explanation: Part 1: Member Information 1. Complete ALL information. Your ID Number can be located on your member ID card. 2. Submit claims within the filing period specified by your Benefit plan. For questions about your filing period please review your Member handbook or call the Customer Care number on your member ID card. 3. Please submit a separate form for each patient for which you purchased medications. 4. Reimbursement will be made directly to the CARDHOLDER unless otherwise noted. First Name Last Name MI Telephone Number ( ) Date of Birth Gender (Circle One) Male Female ID Number Subscriber’s Employer (PCN) Mailing Address City State ZIP Code Member Signature Date Signed Part 2: Pharmacy Information 1. Complete ALL information. 2. Please submit a separate form for each pharmacy from which you purchased medications.

2017-0620W Name Street Address City State ZIP Code Pharmacy National Provider Number (NPI) Telephone Number ( ) Part 3: Receipt Information 1. Include original pharmacy receipt(s) or pharmacy printout(s); Cash Register Receipt(s) without pharmacy detail will not be accepted. Tape original pharmacy receipt(s) to bottom of this page. Please DO NOT staple. 2. Receipt(s) must contain the information outlined under Part 3. If your receipt(s) are missing any of this information, have your pharmacist fill in the missing information under Part 3. 3. Please provide the explanation of benefits (EOB) or denial letter from the primary insurance carrier if you have primary coverage with another insurance carrier. 4. An incomplete form may be denied, delayed or returned. 5. Receipts will not be returned, remember to keep a copy of the completed claim form and receipt(s) for your records. Rx Written Date Date Rx Filled Medication Name Rx Number Diagnosis Code and Description National Drug Code Quantity Day Supply Prescribing Physician First/Last Name Prescribing Physician NPI Original Cost of Rx Amount Primary Insurance Paid on Rx Member Paid Amount Mail this form along with receipts to: Navitus Health Solutions, LLC P.O. Box 999 Appleton, WI 54912-0999 OR Fax this form along with receipt(s) to: (920)735-5315 / Toll Free (855)668-8550