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Get SIGNATURE / RELEASE

Ceipt. Your prescription # Quantity Date of purchase Prescriber DEA# Prescription NDC# Pharmacy NABP# Name of medicine Prescription number Strength of the prescription Total cost for each prescription Day supply Items not covered under your prescription benefit plan should not be submitted for reimbursement including Durable Medical Equipment. Diabetic supplies requiring a prescription are reimbursable only if covered by your plan. Canceled checks and.

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