Get Express Scripts Prescription Drug Claim Form

Filling out the Express Scripts Prescription Drug Claim Form online can help you efficiently manage your prescription reimbursements. This guide provides a comprehensive overview of each section of the form, ensuring that you complete it accurately and successfully.

Follow the steps to complete your claim form effectively

1. Press the ‘Get Form’ button to access the form and open it in your editor.
2. Fill in the cardholder’s name, including last name, first name, and middle initial. This identifies the insured member.
3. Enter the date of birth of the cardholder to confirm eligibility.
4. Indicate the gender of the cardholder by circling 'M' for male or 'F' for female.
5. Provide the cardholder ID number, which can be found on the prescription drug or health insurance card.
6. Include the cardholder’s mailing address, daytime telephone number, and check the box if the address has changed.
7. List the cardholder’s employer, insurance carrier, and group number as provided on the insurance card.
8. Sign and date the form to certify that the information provided is correct and that the prescriptions are for eligible individuals.
9. For each patient submitting claims, provide their name, relationship to the cardholder, gender, date of birth, and the number of prescriptions submitted.
10. Record the pharmacy name and address, along with the prescribing doctor’s name and DEA number for each patient.
11. Answer any specific claim questions, such as whether the claim is for diabetic supplies or if the patient resides in an assisted living facility.
12. Attach all prescription receipts and labels with the necessary information, ensuring they are taped to a separate piece of paper and not stapled.
13. Use the 'Reason for claim submission or special notes' section for any additional comments that may assist in processing your claim.
14. Once all sections are completed and all required documents are attached, save, download, print, or share the claim form as needed.

Start completing your Express Scripts Prescription Drug Claim Form online today for a smoother reimbursement process.