Get Member Reimbursement Form Ohio Caresource

Filing the Member Reimbursement Form online can be a straightforward process when guided by clear instructions. This guide will walk you through each section of the form to ensure that you submit all necessary information for a successful claim.

Follow the steps to complete your form efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your member information. Fill in your first and last name, member ID number, phone number, street address, apartment number (if applicable), city, state, date of birth, and zip code. Ensure all the details are accurate and clearly printed.
3. Proceed to the prescription information section. For each prescription, you need to input details such as the RX number, the date it was filled, the name of the drug along with the NDC number, the pharmacy's NPI number, the strength of the medication, the quantity, the days supply, and the amount you paid.
4. Make sure to attach all prescription receipts to the back of this form. Each receipt must include crucial information: RX number, date filled, Pharmacy NPI#, drug name with NDC number, strength, quantity, days supply, and amount paid.
5. Review the completed form for accuracy. Ensure all required information is filled out and all necessary receipts are attached.
6. Sign the form to certify that the information provided is complete and accurate. Then date your signature.
7. Mail the completed form along with the attached receipts to CVS Caremark, Med D Claims, P.O. Box 52066, Phoenix, AZ 85072-2066.
8. After mailing, you can save the changes in your records if you made a copy, or print the filled form for your personal files.

Complete your forms online today to ensure timely reimbursement.