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Get Catarman Direct Member Reimbursement Form 2011-2024

DIRECT MEMBER REIMBURSEMENT FORM Please attach a detailed receipt from the pharmacy including all of the following information. If this information is not on the receipt please have the pharmacist complete and sign this form and attach proof of payment. Without the required information Catamaran will not be able to process your claim. PRESCRIPTION FILLED FOR Patient Name DATE OF BIRTH Patient DOB PLAN PARTICIPANT IDENTIFICATION NUMBER Printed on prescription card MAILING ADDRESS PLAN NAME Employer or Group Name Rx Pharmacy NABP/NPI Fill Date Drug Name including strength NDC Number Physician DEA/NPI Quantity Days Supply Amount Paid PHARMACIST SIGNATURE PHARMACY PHONE NUMBER All reimbursements are subject to plan terms and conditions and may be reduced from the submitted amounts based on plan cost and copayments. Without the required information Catamaran will not be able to process your claim. PRESCRIPTION FILLED FOR Patient Name DATE OF BIRTH Patient DOB PLAN PARTICIPANT IDENTIFICATION NUMBER Printed on prescription card MAILING ADDRESS PLAN NAME Employer or Group Name Rx Pharmacy NABP/NPI Fill Date Drug Name including strength NDC Number Physician DEA/NPI Quantity Days Supply Amount Paid PHARMACIST SIGNATURE PHARMACY PHONE NUMBER All reimbursements are subject to plan terms and conditions and may be reduced from the submitted amounts based on plan cost and copayments. Any reimbursement due will be refunded to the policyholder. Please check one of the following reimbursement request reasons Member did not have the Catamaran prescription drug card with them Member did not receive the Catamaran prescription drug card before the time of purchase Vacation supply Claim was rejected at the pharmacy Claim consideration for Coordination of Benefits secondary coverage Out-of-network purchase Other please attach a detailed explanation to be considered for reimbursement Fax to 1-888-341-8583 Mail to Catamaran Direct Member Reimbursement P. O. Box 1069 Rockville MD 20849-1069 Any person who knowingly and willfully presents a false or fraudulent claim for payment for a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. 4/11. DIRECT MEMBER REIMBURSEMENT FORM Please attach a detailed receipt from the pharmacy including all of the following information* If this information is not on the receipt please have the pharmacist complete and sign this form and attach proof of payment. Without the required information Catamaran will not be able to process your claim* PRESCRIPTION FILLED FOR Patient Name DATE OF BIRTH Patient DOB PLAN PARTICIPANT IDENTIFICATION NUMBER Printed on prescription card MAILING ADDRESS PLAN NAME Employer or Group Name Rx Pharmacy NABP/NPI Fill Date Drug Name including strength NDC Number Physician DEA/NPI Quantity Days Supply Amount Paid PHARMACIST SIGNATURE PHARMACY PHONE NUMBER All reimbursements are subject to plan terms and conditions and may be reduced from the submitted amounts based on plan cost and copayments. .

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