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Coordination of Benefits/Direct Claim Form

See the back for instructions. Complete all information.

An incomplete form may delay your reimbursement.

Express Scripts recently acquired Medco,

so you will see the Medco name in some

Member/Subscriber Information See your prescription drug ID card.

communications until the renaming

Group No.

process is completed.

Claim Receipts

Member ID

Tape receipts or itemized bills on the back.

See back for details.

Check the appropriate box if any

Member Name (First, Last)

receipts or bills are for a:

Compound prescription

Street Address

Make sure your pharmacist lists ALL

the VALID 11-digit NDC numbers,

ingredients, cost and quantities on

City

State

Zip

the receipt or bill.

Medication purchased outside of

Patient Information

the United States

Please indicate:

Country

Patient Name (First, Last)

Currency used

Patient Date of Birth (Month/Day/Year)

Allergy medication

Sex

Relationship to Plan Member

Coordination of Benefits

Female

Self

Disabled Dependent

(Another Health Plan has paid a

Male

Spouse

Dependent Parent

portion) Mark the appropriate box for

Eligible Child

Nonspouse Partner

Dependent Student

Other

your primary coverage method. See the

back for more information.

Pharmacy Information

Is this a coordination of benefits claim?

Yes

Another Health Plan paid and you

Name of Pharmacy

are enclosing a statement that

outlines how much you paid and

Street Address

how much the other carrier paid.

Card Program

City

State

Zip

Medco Pharmacy¨/mail-order service

Telephone (include area code)

Any person who knowingly and with intent

Is this an on-site nursing home pharmacy? Yes No

to defraud, injure, or deceive any insurance

company submits a claim or application containing

I hereby certify that the charge(s) shown for the medication(s) prescribed is correct and agree to provide Medco or its

any materially false, deceptive, incomplete, or

agents reasonable access to records related to medication dispensed to this patient in accordance with applicable law.

misleading information pertaining to such claim

I further recognize that reimbursement will be paid directly to the plan member and assignment of these benefits to

may be committing a fraudulent insurance act,

a pharmacy or any other party is void.

which is a crime and may subject such person to

criminal or civil penalties, including fines and/or

imprisonment or denial of benefits.*

Signature of Pharmacist or Representative

NABP Number Required

Please tape receipts on the back.

(Required if "yes" is checked above)

Acknowledgment

I certify that the medication(s) described above was received for use by the patient listed above, and that I (or the patient, if not myself) am eligible for prescription drug benefits. I also certify that the medication received was not for an on-the-job injury or covered under another benefit plan. I recognize that reimbursement will be paid directly to me and that assignment of these benefits to a pharmacy or any other party is void.

Signature of Member

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.
Please request that your pharmacy contact Pharmacy Services at 1-800-922-1557 for assistance.	CF5502B 7/12

Claim Receipts

Please tape your receipts here. Do not staple! If you have additional receipts, tape them on a separate piece of paper.

Tape receipt for prescription 1 here.

Receipts must contain the following information:

•Date prescription filled

¥Name and address of pharmacy

¥Doctor name or ID number

¥NDC number (drug number)

¥Name of drug and strength

¥Quantity and daysÕ supply

¥Prescription number (Rx number)

¥DAW (Dispense As Written)

¥Amount paid

Tape receipt for prescription 2 here.

Receipts must contain the following information:

¥Date prescription filled

¥Name and address of pharmacy

¥Doctor name or ID number

¥NDC number (drug number)

¥Name of drug and strength

¥Quantity and daysÕ supply

¥Prescription number (Rx number)

¥DAW (Dispense As Written)

¥Amount paid

PHARMACY INFORMATION (For Compound Prescriptions ONLY)

¥ List the VALID 11-digit NDC number for

Rx #

Date

Days’

EACH ingredient used for the compound

filled

supply

prescription.

¥ For each NDC number, indicate the Òmetric

VALID 11-digit NDC #

Quantity

Price

quantityÓ expressed in the number of

tablets, grams, milliliters, creams, ointments,

injectables, etc.

¥ For each NDC number, indicate cost per

ingredient.

¥ Indicate the TOTAL charge (dollar amount)

paid by the patient.

¥ Receipt(s) must be attached to claim form.

Total quantity

When To Use This Form

Total charge

Instructions

¥ Use this form to submit claims under Coordination of Benefit rules.

¥ You must complete a separate claim form for each pharmacy used and for each patient.

Read carefully before completing this form.

1. Be sure your receipts are complete. In

¥ You must submit claims within 1 year of date of purchase or as required by your plan.

order for your request to be processed, all

Another Health Plan Paid

receipts must contain the information

You must first submit the claim to the primary insurance carrier. Once the statement from the

listed above. Your pharmacist can provide

the necessary information if your claim or bill

primary plan is received from the primary carrier, complete this form, tape the original

is not itemized.

prescription receipts in the spaces provided above, and attach the statement from the primary

plan, which clearly indicates the cost of the prescription and what was paid by the primary plan.

2. The plan member should read the

Prescription Drug Programs or HMO Plans

acknowledgment carefully, and then sign

and date this form.

Retail pharmacies: If the primary plan is one in which a co-payment or coinsurance is paid at

3. Return the completed form and

the pharmacy, then no EOB is needed. Just complete this form and attach the prescription

receipt(s) to:

receipt(s) that shows the co-payment or coinsurance amount paid at the pharmacy. The

receipt(s) will serve as the EOB.

Express Scripts

Medco Pharmacy mail-order service: If the primary plan is mail order, complete this form

P.O. Box 14711

and attach either the prescription receipt(s) that shows the co-payment or coinsurance amount	Lexington, KY 40512

paid to the mail-order pharmacy or the statement of benefits you receive from the mail-order
pharmacy.

* California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Visit us online anytime at www.medco.com

or call TRS-Care Customer Service toll-free at *CF5502B* 1-800-367-3636 and press 2.

CF5502B

7/12

*CF5502B*

Question	Answer
Form Name	Express Scripts Claim Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	express scripts prescription claim form, express scripts appeals, express scripts form, express scripts reimbursement forms

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