Get Express Scripts Prescription Drug Claim Form
MUST be signed by the Pharmacist. CASH REGISTER RECEIPTS ARE NOT ACCEPTABLE FOR ANY PRESCRIPTIONS. (With the exception of diabetic supplies) REASON FOR CLAIM SUBMISSION OR SPECIAL NOTES: ESI USE ONLY P.O. Box 66583 St. Louis, MO 63166-6583 Please return this claim to: Express Scripts, Inc. P.O. Box 66583 St. Louis, MO 63166-6583 ATTN: NGC STD ACCTS PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY AND COMPLETE FORM ON REVERSE SIDE. Cardholder s Information (The Cardholder is the insure.
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