ESI Member Reimbursment Form

Prescription Drug Reimbursement Form
See the back for instructions. Complete all information.
An incomplete form may delay your reimbursement.
Member/Subscriber Information See your prescription drug ID card.
Health Plan Name
Member Name (First, Last)
Street Address
City
State
ZIP
Patient Information
Patient Name (First, Last)
Patient Date of Birth (Month/Day/Year)
Sex
Relationship t o Plan Member
 Female  1 Self

 Male  2 Spouse

 3 Eligible Child

 4 Dependent Student 
5
6
7
8
Disabled Dependent
Dependent Parent
Nonspouse Partner
Other
Claim Receipts
Tape receipts or itemized bills on
the back.
See back for details.
Check the appropriate box if any
receipts or bills are for a:
 Compound prescription
Make sure your pharmacist lists
ALL the VALID NDC numbers,
cost and quantities for each
ingredient on the back of this
form and attach receipts. Claim
will be returned
if incomplete.
ONE CLAIM FORM
PER COMPOUND
SUBMISSION
 Allergy medication
Pharmacy Information
Name of Pharmacy
Street Address
City
State
ZIP
Telephone (include area code)
Is this an on-site nursing home pharmacy? Yes No
I hereby certify that the charge(s) shown for the medication(s) prescribed is correct and agree to provide
Express Scripts or its agents reasonable access to records related to medication dispensed to this patient in
accordance with applicable law. I further recognize that reimbursement will be paid directly to the plan
member and assignment of these benefits to a pharmacy or any other party is void.
Please tape receipts on the back.
X
Signature of Pharmacist or Representative
(Required)
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.*
NABP Number Required
Acknowledgment
I certify that the medication(s) described above was received for use by the patient listed above, and that I (or the patient, if not myself) am
eligible for prescription drug benefits. I also certify that the medication received was not for an on-the-job injury or covered under another
benefit plan. 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.*
X
Signature of Member
Date
*If allowed by law, you may assign the payment of this claim to your pharmacy. If your pharmacy is willing to accept assignment, do not complete this form.
Please request that your pharmacy contact Pharmacy Services at 1 800 922-1557 for assistance.
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Claim Receipts
Please tape your receipts here. Do not staple! If you have additional receipts, tape them on a separate piece of paper.
Tape receipt for prescription 1 here.
Receipts must contain the
following information:
• Date prescription filled
• Name and address of pharmacy
• Doctor name or ID number
• NDC number (drug number)
• Name of drug and strength
• Quantity and days’ supply
• Prescription number (Rx number)
• DAW (Dispense As Written)
• Amount paid
Tape receipt for prescription 2 here.
Receipts must contain the
following information:
• Date prescription filled
• Name and address of pharmacy
• Doctor name or ID number
• NDC number (drug number)
• Name of drug and strength
• Quantity and days’ supply
• Prescription number (Rx number)
• DAW (Dispense As Written)
• Amount paid
PHARMACY INFORMATION (For Compound Prescriptions ONLY)
• List the VALID 11-digit NDC number for
EACH ingredient used for the compound
prescription.
• For each NDC number, indicate the “metric
quantity” expressed in the number of
tablets, grams, milliliters, creams, ointments,
injectables, etc.
• For each NDC number, indicate cost per
ingredient.
• Indicate the TOTAL charge (dollar amount)
paid by the patient.
• Receipt(s) must be attached to claim form.
Date
filled
Rx #
VALID 11-digit NDC #
Days’
supply
Quantity
Price
Total quantity
Total charge
Direct Reimbursement Claim Instructions
Read carefully before completing this form.
1. Always present your prescription drug ID card at the participating
retail pharmacy.
2. Only use this claim form when you have paid full price for a
prescription drug order at a pharmacy because:
• The pharmacy does not accept your Express Scripts prescription
drug ID card, or
• You have not received your Express Scripts prescription drug ID card.
3. You must complete a separate claim form for each pharmacy used
and for each patient.
5. Be sure your receipts are complete.
In order for your request to be processed, all receipts must contain
the information listed above. Your pharmacist can provide the
necessary information if your claim or bill is not itemized.
6. The plan member should read the acknowledgment carefully, and
then sign and date this form.
7. Return the completed form and receipt(s) to:
Express Scripts
P.O. Box 14711
Lexington, KY 40512
4. You must submit claims within 1 year of date of purchase or as
required by your plan.
* 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 is guilty of a crime and may be subject to
fines and confinement in state prison.
Visit us online anytime at Express-Scripts.com
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