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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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© Copyright 1997-2026
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Your Privacy Choices
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Help Portal
Legal Resources
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
altaFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2026
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232