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Er If you are enrolled in Medicare, check here Employee Name (First, Middle, Last) Employee Birthdate (MM/DD/YYYY) Employee Address (Street, City, State, ZIP Code) Company Name & Address (Street, City, State, ZIP Code) Employee Signature Telephone Number ( Date ) Prescription(s) were for: Last Name, First, Middle Initial Employee Gender Male Spouse Dependent Patient Birthdate (MM/DD/YYYY) Female Are any family members expenses covered by another group health plan, group pre-payme.

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How to fill out the Aetna pharmacy management prescription drug claim form online

This guide provides clear and comprehensive instructions for users on how to fill out the Aetna pharmacy management prescription drug claim form online. By following the outlined steps, individuals can ensure a smooth submission process for their claims.

Follow the steps to complete your prescription drug claim form accurately.

  1. Press the ‘Get Form’ button to access the prescription drug claim form and open it for editing.
  2. Provide your Aetna member number at the top of the form. This number is essential for processing your claim.
  3. Enter your group number in the designated field. This information helps identify your specific insurance plan.
  4. If you are enrolled in Medicare, check the corresponding box to provide this information.
  5. Complete the employee's full name, including first, middle, and last names.
  6. Input the employee's birthdate using the format MM/DD/YYYY.
  7. Fill in the employee's address, including street, city, state, and ZIP code.
  8. Provide the company name and address where the employee is employed.
  9. Include the employee's signature and telephone number in the specified sections.
  10. Indicate the patient’s information, including last name, first name, and middle initial, as well as their gender and birthdate.
  11. Answer the question regarding coverage by other health plans, and if applicable, provide the necessary details of the other coverage.
  12. If you need to manually file the claim, indicate the reason and attach any required documentation, such as an Explanation of Benefits.
  13. Attach detailed prescription receipts as proof of purchase. Claims cannot be processed without this attachment.
  14. Carefully review all completed fields for accuracy and completeness to avoid delays in processing.
  15. Once all information is finalized, submit the claim form via mail or fax to the provided Aetna Pharmacy Management address.

Complete your prescription drug claim form online today for a hassle-free experience.

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