Get Express Scripts Form

Filling out the Express Scripts Form online can simplify your reimbursement process for prescription medications. This guide provides clear instructions to help you complete each section accurately and efficiently.

Follow the steps to successfully fill out the Express Scripts Form.

1. Press the ‘Get Form’ button to access and open the Express Scripts Form in the editing interface.
2. Begin by entering your member or subscriber information. Refer to your prescription drug ID card for the group number, member ID, and your full name (first and last). Fill in your street address, city, state, and zip code.
3. Next, provide the patient's information. Fill in the patient's name, date of birth, and sex. Indicate their relationship to the plan member by selecting one of the options provided, such as 'self,' 'spouse,' or 'eligible child.'
4. Then, complete the pharmacy information section. Enter the name of the pharmacy, its address, city, state, and zip code. Include the pharmacy's telephone number, and indicate if it is an on-site nursing home pharmacy.
5. You must sign the form in the pharmacist or representative signature section, providing the required NABP number as well.
6. Next, tape your claim receipts or itemized bills on the back of the form. Ensure all receipts contain necessary information, including prescription filled date, pharmacy name and address, doctor's name or ID, NDC number, drug name, quantity, prescription number, and amount paid.
7. If applicable, mark whether this is a coordination of benefits claim. If another health plan contributed to the payment, ensure to include their payment statement along with your claim.
8. Finally, review all provided information for accuracy. Once complete, make sure to save your changes, and if necessary, download, print, or share the form.

Complete your Express Scripts Form online today for a seamless reimbursement experience.