Get Gateway Health Plan Pharmacy Direct Reimbursement Form

This guide provides step-by-step instructions on how to complete the Gateway Health Plan Pharmacy Direct Reimbursement Form online. Whether you are new to the process or just need a refresher, this resource will assist you in navigating each section of the form effectively.

Follow the steps to complete your reimbursement form with ease.

1. Press the ‘Get Form’ button to access the Gateway Health Plan Pharmacy Direct Reimbursement Form and open it in your chosen editor.
2. In Part 1, enter your Member ID found on your Gateway Health Plan ID card. Then, fill in your name, address, and telephone number. Include your date of birth in the format of Month, Day, Year.
3. Sign the form at the designated area to certify the accuracy of the information provided. If the member does not complete the form themselves, a guardian or legal representative must sign.
4. In Part 2, provide the pharmacy information. Enter the pharmacy name, address, and telephone number where the prescription was purchased.
5. For each prescription, fill out the corresponding RX fields (RX1, RX2, RX3, and RX4). This includes the date of service, prescription number, NDC number, amount paid, quantity, days supply, and prescriber name.
6. Ensure you complete separate forms for each pharmacy if you had prescriptions filled at multiple locations.
7. Once the form is filled out completely, save your changes, and you may choose to download, print, or share the form as needed for submission.

Complete your Gateway Health Plan Pharmacy Direct Reimbursement Form online today for efficient reimbursement processing.