Get Express Scripts Direct Claim Form

The Express Scripts Direct Claim Form is designed to facilitate the reimbursement process for prescription medications. This guide provides clear, step-by-step instructions on how to fill out this form online, ensuring all necessary information is captured accurately for efficient processing.

Follow the steps to successfully complete the Express Scripts Direct Claim Form online.

1. Press the ‘Get Form’ button to access the form and open it within your preferred online platform.
2. Enter the cardholder's name in the designated field, including the last name, first name, and middle initial.
3. Provide the cardholder's date of birth in the appropriate format.
4. Indicate the gender of the cardholder by selecting 'M' for male or 'F' for female.
5. Fill in the cardholder ID number, which can be found on the insurance card.
6. If applicable, check the box to indicate if there is a new address for the cardholder.
7. Complete the mailing address fields including street, city, state, and zip code, along with a daytime telephone number.
8. Identify the cardholder's employer, insurance carrier, and group number as needed.
9. Obtain the cardholder's signature and date in the respective section, certifying the accuracy of the information provided.
10. For each patient submitting claims, list their name, relationship to the cardholder, gender, and date of birth in the patient information section.
11. Indicate the number of prescriptions attached for each patient and provide the name and address of the pharmacy where prescriptions were filled.
12. Answer any specific questions provided in the claim form, such as whether the claim is for diabetic supplies or allergy serum.
13. Attach all required prescription receipts or labels, ensuring they contain necessary data such as pharmacy name, drug name, quantity, and more.
14. Utilize the special notes section for any additional information that may support the claim.
15. Save your changes, then download, print, or share the completed form as required.

Begin filling out the Express Scripts Direct Claim Form online today for a smooth claims process.