Get Vrx Prescription Reimbursement Claim Form

Filling out the VRx Prescription Reimbursement Claim Form online can streamline the process of submitting your prescription costs for reimbursement. This guide provides step-by-step instructions to help you accurately complete the form, ensuring a smooth submission experience.

Follow the steps to complete your claim form online.

1. Click ‘Get Form’ button to access the form and open it in your document editor.
2. Provide your member or subscriber information. Fill in your name, member ID number, mailing address, city, state, and zip code as indicated on your ID card.
3. Input patient information. Enter the patient's name, gender, and date of birth. Then, specify the relationship of the patient to the subscriber, selecting from options: self, spouse, child, or other.
4. Indicate whether the patient has other prescription drug coverage. If 'yes,' ensure to gather the required pharmacy receipts identifying copays paid and an explanation of benefits from the primary carrier or prescription history from the pharmacy.
5. In the prescription information section, attach the original pharmacy receipts or pharmacy printouts. Ensure that these documents include essential details such as the date filled, 11-digit national drug code (NDC#), Rx number, member paid amount, medication name and strength, pharmacy name, quantity received, pharmacy ID number, day supply of medication, and physician name and/or DEA number.
6. Review all provided information for accuracy and completeness. Certification of the provided information is required, so ensure everything is correct.
7. Sign and date the form to authorize VRx and health care providers to secure or release any necessary information related to this claim.
8. Once all fields are completed and verified, save your changes, download, print, or share the form as needed.

Start filling out your VRx Prescription Reimbursement Claim Form online today to manage your prescription reimbursements efficiently.