Get 1199 Pharmacy Reimbursement Form

Completing the 1199 Pharmacy Reimbursement Form online can streamline the process of obtaining reimbursement for your pharmacy expenses. This guide offers clear, step-by-step instructions to help you accurately fill out each section of the form.

Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Fill in the Member/Subscriber Information section. Locate your ID card and input the Rx Group, Member ID, and Member Name (First and Last). Provide your street address, city, state, and zip code.
3. Move to the Patient Information section. Enter the Patient Name (First and Last) and the Patient Date of Birth (Month/Day/Year). Indicate the patient's Gender and Relationship to Member/Subscriber by selecting the appropriate options.
4. Complete the Pharmacy Information section. List the Name of the Pharmacy, their street address, city, state, and zip code, along with their telephone number (including area code).
5. In the Claim Receipts section, check the box that corresponds to your receipts: Compound prescription, Medication purchased outside of the United States, or Allergy medication if covered by your pharmacy plan.
6. If this claim is a Coordination of Benefits claim, answer 'Yes' or 'No' and follow the instructions for further details, as noted in Section B.
7. Ensure that the necessary documentation is attached. Tape all receipts (not cash register receipts) onto the designated section of the claim form, ensuring they contain required information as noted in the instructions.
8. Lastly, review the acknowledgment carefully. Both the Member/Subscriber and, if applicable, the pharmacist or representative should sign and date the form. Check for completeness and ensure all required information is provided.
9. Once completed, save your changes, download the form, print it, and share as necessary.

Start filling out your 1199 Pharmacy Reimbursement Form online to ensure timely reimbursement for your pharmacy expenses.