Health Insurance Marketplace Prescription Drug Reimbursement Claim Form

Instructions: Please read carefully or claims may be returned. Save time and money. In the future, present your BCBSM ID card at a participating pharmacy and ask them to submit your prescription claim electronically. We have over 50,000 pharmacies in our network.

Submission Requirements The claim must be submitted within one year of the date of service. Claims over one year will not be reimbursed. If submitting a foreign claim, you must also complete the Foreign Prescription Drug Reimbursement Claim Form. Pharmacy receipts are REQUIRED. Cash register receipts will not be accepted. Pharmacy receipts may include the following information:

Pharmacy name, address and telephone number Patient name Prescription number Date of service Name of prescription dispensed National Drug Code (NDC) Quantity Day supply Amount paid

General Instructions

1. Complete this claim form if you paid full price for a prescription drug at a retail pharmacy or for Coordination of Benefits. If your coverage provides prescription discounts, you may not be reimbursed.

Is BCBSM your primary insurance? Did the pharmacy already submit a claim and apply a deductible? If yes, do not submit a claim. Deductibles must be met before a copay is charged.

2. You must complete a separate claim form for each pharmacy used and for each patient. 3. Attach pharmacy receipts. See the Submission Requirements section above. Ask your pharmacist to provide

information if your claim or bill is not itemized. 4. Read the acknowledgement carefully and sign and date the claim form. A signature is REQUIRED. 5. Return the completed claim form and receipt(s) to:

BCBSM Mail Code 510 - L 600 E. Lafayette Blvd. Detroit, MI 48226-2998 Or you may fax your claim form to 866.714.5094. Use one claim form per fax. Do not combine claims for different patients.

If you have questions, call the Customer Service number located on the back of your Blue Cross Blue Shield of Michigan ID card or visit us at bcbsm.com.

Express Scripts is an independent company that provides pharmacy services for Blue Cross Blue Shield of Michigan.

ML6760D

Save time and money. In the future, present your BCBSM ID card at a participating pharmacy and ask them to submit yourprescription claim electronically. We have over 50,000 pharmacies in our network.

Express Scripts ATTN: Commercial Claims P.O. Box 14711 Lexington, KY 40512-4711

Or you may fax your claim form to: 608.741.5475. Use one claim form per fax. Do not combine claims for different patients.

If you have questions, call the Customer Service number located on the back of your Blue Cross Blue Shield ofMichigan ID card or visit us at bcbsm.com.

Save time and money. In the future, present your Blue Cross Blue Shield of Michigan ID card at a participating pharmacy and ask

them to submit your prescription claim electronically. We have over 50,000 pharmacies in our network.

National Drug Code, also referred to as NDC

Is Blue Cross your primary insurance? Did the pharmacy already submit a claim and apply a deductible?

If yes, do not submit a claim. Deductibles must be met before a copay is charged.

Or you may fax your claim form to: 608-741-5475. Use one claim form per fax.

Do not combine claims for different patients.

If you have questions, call the Customer Service number located on the back of your Blue Cross Blue Shield of

Michigan ID card or visit us at bcbsm.com.

Prescription Drug Reimbursement Claim Form » Coordination of Benefits Instructions

If another health plan paid: 1. You must first submit the claim to the primary insurance carrier. Once you receive the statement from the primary

plan, complete this claim form and indicate the secondary group number and Enrollee ID in the Cardholder Information section.

2. Attach the original receipts and the statement from the primary plan to this claim form. The primary plan statement should clearly indicate the cost of the prescription and what was paid by the primary plan.

Coordination of Benefits If the primary plan processed the claim at a retail pharmacy, then no Explanation of Benefits is needed. Just complete this claim form and attach the prescription receipt(s) that shows the copayment or coinsurance amount paid at the pharmacy. The receipt(s) will serve as the Explanation of Benefits.

Mail Order Pharmacy If the primary plan processed the claim, complete this claim form and attach either the prescription receipt(s) that shows the copayment or coinsurance amount paid or the statement of benefits you received.

Express Scripts is an independent company that provides pharmacy services for Blue Cross Blue Shield of Michigan

If another health plan paid:

2. Attach the original receipts and the statement from the primary plan to this claim form. The primary plan statement should clearly indicate the cost of the prescription and what was paid by the primary plan.

1. You must first submit the claim to the primary insurance carrier. Once you receive the statement from the primary plan, complete this claim form and indicate the secondary group number and Enrollee ID in the Cardholder Information section.

Coordination of Benefits If the primary plan processed the claim at a retail pharmacy, then no Explanation of Benefits is needed. Just complete this claim form and attach the prescription receipt(s) that shows the copayment or coinsurance amount paid at the pharmacy. The receipt(s) will serve as the Explanation of Benefits.

Mail Order Pharmacy If the primary plan processed the claim, complete this claim form and attach either the prescription receipt(s) that shows the copayment or coinsurance amount paid or the statement of benefits you received.

Prescription Drug Reimbursement Claim FormBe sure to complete the detailed claim information on the back of this form. Claims may be returned if incomplete.

Enrollee Name: First Last

Street Address

City State ZIP

Daytime Telephone (include area code)

Patient InformationPatient Name: First Last

Patient Date of Birth (MM/DD/YYYY)

Sex Relationship to Enrollee

1 Self

2 Spouse

3 Eligible Dependent

Female

Male

Pharmacy InformationName of Pharmacy

Street Address

City State ZIP

Telephone (include area code)

Is this an on-site nursing home pharmacy? Yes No

Compound prescriptionMake sure your pharmacist lists ALL of theVALID NDC numbers, quantities, and cost foreach ingredient on the back of this claim formand attach your receipt. Claim may be returnedif incomplete.ONLY ONE CLAIM FORM NEEDED PER COMPOUND PRESCRIPTION

Foreign – prescription purchased outsideof the United StatesPlease complete the additional ForeignPrescription Drug Reimbursement ClaimForm.Please indicate:

ML6760D Express Scripts is an independent company that provides pharmacy services for Blue Cross Blue Shield of Michigan.

COORDINATION OF BENEFITS:If another health plan has paid a portion, please seethe Coordination of Benefits Instructions.

Is this a Coordination of Benefits claim?

I certify that the medication(s) described was received for use by the patient listed above, and that I (or the patient, if not myself) am eligible for prescriptiondrug benefits. I certify that the medication(s) described were not for an on-the-job injury. By completing this form, I recognize that reimbursement will be paid directly to me and that assignment of these benefits to a pharmacy or any other party is void.

Date

Any person who knowingly and with intent to defraud, injure, or deceive any insurance company submits a claim or application containing any materially false, deceptive, incomplete, or misleading information pertaining to such claim may be committing a fraudulent insurance act, which is a crime and may subject such person to criminal or civil penalties, including fines and/or imprisonment or denial of benefits.†

Yes No

Check the appropriate box if your receipt or bill is for:

Allergy medication

Country

Cardholder Information (refer to your BCBSM ID card). USE THE ID# YOU WANT THE CLAIMS PROCESSED UNDER.

Check your RxGrp � BCBSMRX1 � BCBSMAN

Enrollee ID(numeric ONLY)

Group Number

Currency used

Enrollee or Patient Signature - (REQUIRED)

Prescription Drug Reimbursement Claim Form

Cardholder Information (refer to your Blue Cross ID card).

Enrollee ID (last nine numbers only)Example: X4Z123456789

PHARMACY CLAIM RECEIPTS ARE REQUIREDPlease attach your detailed pharmacy receipts (keep a copy for your records). Cash register receipts will not be accepted.Claims may be returned if incomplete. • Claims with a date of service older than one year will not be reimbursed. • If submitting a foreign claim, you must also complete the Foreign Prescription Drug Reimbursement Claim Form.

Complete the claim information below. Refer to your detailed pharmacy receipt or contact your pharmacist for missing information.

COMPOUND PRESCRIPTION ONLY

Prescription #

Date of Service Quantity Day Supply

Valid 11-digit Ingredient NDC Number Metric Quantity Ingredient Cost

• List the 11-digit NDC number for each ingredient used for the compound prescription.

• For each NDC number, indicate the metric quantity specified; number of tablets, grams, milliliters, etc.

• For each NDC number, indicate cost per ingredient.

• Indicate the amount paid.

• Receipt must be attached to the claim form.

Amount Paid

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Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

† California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss isguilty of a crime and may be subject to fines and confinement in state prison.

© 2016 Express Scripts Holding Company. All Rights Reserved. C 8105 (12-1608 rev 8/16) CRP16_2373

DATE OF SERVICEMM/DD/YYYY PRESCRIPTION # NAME OF PRESCRIPTION NATIONAL DRUG CODE

(NDC is 11 digits) QTY AMOUNTPAID

1

2

3

4

5

6

30DAY

90DAY

OTHER(Specify)

DAY SUPPLY

Return the completed claim form and receipt(s) to:

Express Scripts ATTN: Commercial Claims P.O. Box 14711 Lexington, KY 40512-4711

You may fax your claim form to: 608.741.5475. Use one claim form per fax.

Do not combine claims for different patients.

© 2017 Express Scripts Holding Company. All Rights Reserved. C 8105 (12-1608 rev 4/17) CRP16_2373

You may fax your claim form to: 608-741-5475. Use one claim form per fax.

Do not combine claims for different patients.