Get Federal Employee Program Retail Prescription Drug Overseas Claim Form Instructions This Form Is To

This guide provides comprehensive instructions for completing the Federal Employee Program Retail Prescription Drug Overseas Claim Form. By following these steps, you can ensure accurate submission for reimbursement of prescriptions purchased outside the United States.

Follow the steps to successfully complete your claim form.

1. Click ‘Get Form’ button to obtain the form and open it in an editable format.
2. Fill in the enrollee’s or policy holder’s information. Provide your identification number, full name, street address, email address, city, state, zip code, and country.
3. Complete the patient information section. Enter the patient's name, date of birth, and their relationship to the insured (self, spouse, or dependent).
4. In the foreign country information field, specify the country where the drugs were purchased.
5. For the prescription claim information, list each medication on a new line. Fill out the details for date purchased, quantity, days supply, name of medication, U.S. drug equivalent name, form of medication, strength, and prescription cost.
6. After filling out all required fields, ensure that you sign the form and enter the date at the designated area.
7. Do not staple any receipts or attachments to the form. Keep photocopies of the completed claim form and all supporting documentation for your records.
8. Submit the completed form along with the prescription drug receipts/bills to the address provided on the front of the form or fax it to the specified number.
9. Save changes to your document and ensure you download or print a copy for your personal records.

Start filling out your claim form online today to ensure a smooth reimbursement process.