Express Scripts Claim Form

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Express Scripts Claim Form - Reason for claim submission or special notes This section can be used for special notes or comments Questions Call Express Scripts Customer Service Department at 1 866 387 0435 Please return this claim to Express Scripts Inc Member Reimbursements PO Box 66583 St Louis MO 63166 ATTN Claims Department

Claim Receipts Please read Section A on back for details Check the appropriate box if your receipts are for a Compound prescription Make sure your pharmacist lists ALL the VALID 11 digit NDC numbers and ingredients and quantities on the receipt Medication purchased outside of the United States Please indicate Country Currency used

Express Scripts Claim Form

Express Scripts Claim Form

Express Scripts Claim Form

Log in to express-scripts.com and select Benefits > Forms & Cards Cardholder Information See your prescription drug ID card. Group No. Member ID Claim Receipts Tape receipts or itemized bills on the back. Check the appropriate box if applicable: Member Name First Last Street Address City State ZIP Patient Information Patient Name First Last

What you ll need to submit an online claim Pharmacy receipt To get reimbursed for the money spent on medicine that your plan covers we ll ask you for an image of your pharmacy receipt We can t process any claim for reimbursement without a pharmacy receipt Your pharmacy receipt is not your cash register receipt

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Claim A request for payment submitted to your health insurance by you or by your healthcare provider This request is for any services you think might be covered by your plan If you can t find the answer to your question please contact us Millions trust Express Scripts for safety care and convenience

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To submit a pharmacy claim online you will need to register for an online account Once registered follow the steps below If you already have an online account simply log in to get started Once logged in navigate to the Benefits menu option and select Forms

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By completing this form I recognize that reimbursement will be paid directly to me and that assignment of these bene ts to a pharmacy or any other party is void X Signature of Member Date If allowed by law you may assign the payment of this claim to your pharmacy If your pharmacy is willing to accept assignment do not complete this form

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The Prescription Drug Claim Form is offered as a tool to assist in getting your claim paid as soon as possible Please print clearly Use of the form is not required You may submit equivalent written documentation but it must provide allof the requested information on this form

Learn how to enable JavaScript in your browser. Log in to your Express Scripts account to manage your prescriptions, order a refill, price a medication or view claim status.

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2 Complete the claim form continued Receipts Upload at least one pharmacy receipt with this request An acceptable pharmacy receipt includes prescription

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Express Scripts Claim Form

The Prescription Drug Claim Form is offered as a tool to assist in getting your claim paid as soon as possible Please print clearly Use of the form is not required You may submit equivalent written documentation but it must provide allof the requested information on this form

Claim Receipts Please read Section A on back for details Check the appropriate box if your receipts are for a Compound prescription Make sure your pharmacist lists ALL the VALID 11 digit NDC numbers and ingredients and quantities on the receipt Medication purchased outside of the United States Please indicate Country Currency used

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