Section 1: Member Information

Section 1: Member Information
Last Name / First Name / Middle Initial
Mailing Address / City / State / ZIP Code
Phone Number
( ) / Date of Birth
____/____/______/ Gender / Prescription Advantage Member ID Number:
Name of Primary Insurer (i.e. Humana, Tufts, SilverScript, etc.) / Primary Insurance Plan Name (i.e. Premier, Gold, Option 1-3, etc.)
Section 2: Signature
I certify that all information on this claim form is accurate. I also certify that the patient for whom this claim is made was a covered person in Prescription Advantage and that the prescription is for the sole use of the named patient. I understand that Prescription Advantage use or disclosure of individually identifiable health information, whether furnished by me or obtained from another source such as a medical provider, is in accordance with federal privacy regulations under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
______
Member’s Signature Date
Section 3: Pharmacy Information
Pharmacy Name / Phone Number / NCPDP or NABP Number - (on receipt or please contact pharmacy)
Address / City / State / ZIP Code
Section 4: Prescription Claims Information
Claim #1 Must be within 12 months of Date of Fill
Drug Name / NDC Number – (on prescription receipt or please contact pharmacy) / Prescription Number
Date of Fill / Is this a new prescription or a refill?
c New c Refill / Dosage (250 mg, etc.) / Quantity
Days Supply / Form (capsules, cream, etc.) / Prescriber’s (Doctor’s) Name or DEA Number
Total Charge
$ / Amount Primary Insurance Paid (if not on receipt please contact Primary Insurer for this information)
$ / Amount You Paid
$
Claim #2 Must be within 12 months of Date of Fill
Drug Name / NDC Number –(on prescription receipt or please call pharmacy) / Prescription Number
Date of Fill / Is this a new prescription or a refill?
c New c Refill / Dosage (250 mg, etc.) / Quantity
Days Supply / Form (capsules, cream, etc.) / Prescriber’s (Doctor’s) Name or DEA Number
Total Charge
$ / Amount Primary Insurance Paid (if not on receipt please contact Primary Insurer for this information)
$ / Amount You Paid
$
Claim #3 Must be within 12 months of Date of Fill
Drug Name / NDC Number –(on prescription receipt or please call pharmacy) / Prescription Number
Date of Fill / Is this a new prescription or a refill?
c New c Refill / Dosage (250 mg, etc.) / Quantity
Days Supply / Form (capsules, cream, etc.) / Prescriber’s (Doctor’s) Name or DEA Number
Total Charge
$ / Amount Primary Insurance Paid (if not on receipt please contact Primary Insurer for this information)
$ / Amount You Paid
$
Claim #4 Must be within 12 months of Date of Fill
Drug Name / NDC Number –(on prescription receipt or please call pharmacy) / Prescription Number
Date of Fill / Is this a new prescription or a refill?
c New c Refill / Dosage (250 mg, etc.) / Quantity
Days Supply / Form (capsules, cream, etc.) / Prescriber’s (Doctor’s) Name or DEA Number
Total Charge
$ / Amount Primary Insurance Paid (if not on receipt please contact Primary Insurer for this information)
$ / Amount You Paid
$