Attach Pharmacy Receipt for each claim submitted Review, sign, and send to: ProAct Pharmacy Services, Inc 1230 US HWY 11 Gouverneur, NY 13642 Attn: DMR Dept. IMPORTANT: MISSING INFORMATION MAY CAUSE A DELAY IN PAYMENT. PART A Employee/Patient information Employee s Name: Last First Member # (on ID Car Patient s Name: Last First Relationship to Employee Employee s Street Address City Group ID#(on Card) Employer/Carrie State Employee s Daytime Phone # ( ) Zip Code Ple.
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How to fill out the Proact Claims Form online
Filling out the Proact Claims Form is an essential step for users seeking reimbursement for their pharmacy expenses. This guide will provide you with clear and comprehensive instructions to help you navigate the online form efficiently.
Follow the steps to complete your reimbursement form accurately.
- Click ‘Get Form’ button to obtain the Proact Claims Form and access it in your preferred format.
- In Part A, fill in your employee and patient information. Provide the last name, first name, member number (as indicated on your ID card), patient's last and first name, their relationship to you, your street address, city, state, zip code, and daytime phone number.
- Clearly explain the reason the patient paid the full amount out of pocket in the designated area.
- In Part B, enter prescription information including days supply, Rx number, Rx date, NDC number, quantity, amount paid, and copay.
- Review all entered information to ensure accuracy, as missing information may delay payment.
- Sign and date the authorization statement to certify that the information is correct and authorize necessary parties to release any required information.
- Indicate whether the form is approved for processing by circling 'YES' or 'NO'.
- Ensure all receipts from the pharmacy are attached to the claim and send the completed form to ProAct Pharmacy Services at the provided address.
- Once submitted, you can keep a copy for your records. You may also download, print, or share the completed form as necessary.
Start filling out your Proact Claims Form online today for a smoother reimbursement process.
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How do I contact ProAct?
To contact ProAct, you can visit their official website where you'll find various ways to reach their customer service team. Whether you prefer phone or email, they provide multiple contact methods. Additionally, accessing the Proact Claims Form on their website allows you to find specific inquiries related to your benefits.
Who are the big 3 PBM companies?
The big three PBM companies are Express Scripts, CVS Caremark, and OptumRx. These companies dominate the market due to their extensive networks and resources. Comparing their services with ProAct can provide insights into different options available through the Proact Claims Form.
What is the phone number for ProAct support?
To reach ProAct support, you can contact them at their dedicated customer service number, which is available on their official website. The support team is ready to assist you with any questions regarding the Proact Claims Form or any other inquiries. Whether you need help with claims processing or have questions about your benefits, the ProAct support team is just a call away.
What is the ProAct discount?
The ProAct discount is a structured savings program designed to provide members with lower prescription costs. It is particularly useful for individuals without insurance or those seeking alternatives to high-priced medications. By utilizing the ProAct Claims Form, users can make the most of these discounts available through the ProAct platform.
What is the phone number for ProAct prior authorization?
Prior Authorization Form Navigator If you do not have the bin number please contact 1-877-635-9545.
What is the phone number for ProAct prompt PA?
You or your pharmacist should call ProAct's 24/7/365 Help Desk (1-877-635-9545) immediately for a resolution. Your physician can start the prior authorization review process by visiting proactrx.promptpa.com to obtain medication specific request forms.
Is ProAct an insurance company?
ProAct, Inc. is a fully integrated pharmacy benefit management (PBM) company with a mail order pharmacy. At ProAct, we strive to produce innovative, affordable and flexible prescription drug benefit solutions for the client by combining industry-leading client service with the latest in PBM technology.
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