583522i Prescription Drug Claim Form

Prescription Drug Claim Form
Insured and/or Administered by
Connecticut General Life Insurance Company
Cigna Health and Life Insurance Company
Cigna HealthCare*
REASON FOR REIMBURSEMENT
This claim form can be used to request reimbursement of covered expenses. Please check which reason applies (at least one must be
checked):
Emergency
Non-Participating Pharmacy
Primary coverage is with another insurance carrier. Please
provide explanation of benefits (EOB) or denial letter from the
primary insurance carrier.
Compound Prescription (Pharmacist: Please list ALL the
VALID 11-digit NDC numbers, ingredients and quantities
on the receipt.
Eligibility (Please explain)
Other (Please explain)
PARTICIPANT/PATIENT INFORMATION
Participant Name:
Employer:
Cigna ID Number or Participant Social Security Number: (on the front of your Cigna ID card)
Account Number: (on the front of your Cigna ID card)
Patient Name (use a separate form for each family member):
Patient Birth Date: (Mo., Day, Year)
Patient Relationship to Participant:
Self (Participant)
Patient Sex:
Spouse
Dependent
Male
Female
I represent that the patient information entered on this form is correct, that the patient named is eligible for the benefits and that the patient has
received the medication described. I also represent that the medication received is not for treatment of an on-the-job injury. I also authorize release
of all information pertaining to this claim to the plan administrator or its designees.
Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement of
claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact thereto,
commits a fraudulent insurance act which is a crime. For residents in the following states, please see the last page of this form: Alaska, Arizona,
California, Colorado, District of Columbia, Florida, Kentucky, Maryland, Minnesota, New Jersey, New York, Oregon, Pennsylvania, Tennessee, Texas
and Virginia.
Patient Signature:
Date:
Daytime Phone Number:
PRESCRIPTION INFORMATION
PRESCRIPTION
INFORMATION
For Health Care Reform related Over-the-Counter reimbursement requests, include your Doctor’s prescription.
1)
2)
_____ / _____ / _____
______________
________
DATE FILLED
RX NUMBER
QTY
DRUG NAME & STRENGTH
NDC
PHARMACY NAME
_____________
DAY SUPPLY
$
AMT. PAID
PHARMACY NABP
PHARMACY ADDRESS
_____ / _____ / _____
______________
________
DATE FILLED
RX NUMBER
QTY
DRUG NAME & STRENGTH
NDC
PHARMACY NAME
_____________
DAY SUPPLY
$
AMT. PAID
PHARMACY NABP
PHARMACY ADDRESS
Multi-Ingredient Compound Prescription Information - To be Completed by Dispensing Pharmacy.
Pharmacist: Please fill out one form for each multi-ingredient compound prescription. If submitting more than one compound prescription,
please copy the form and submit one for each. Thank you.
Information below is required to process multi-ingredient claim submissions. For each NDC number, indicate the "metric quantity" expressed in the
number of tablets, grams, milliliters, injectables, etc. and the cost. Receipt(s) must be attached to claim form showing prescribing Physician's Name,
Address, and DEA #.
#
583522i Rev. 12/2012
Quantity
NDC
Drug Name
Charge
INSTRUCTIONS
PARTICIPANT/PATIENT INFORMATION (To be completed by the Participant)
1.
Complete ALL information on the front side. Claims missing information may be denied, delayed or
returned.
2.
Sign and date the Certification Statement in the area provided.
3.
Complete the RETURN ADDRESS section below.
4.
Submit a separate form for each family member.
5.
The Prescription Information section must be completed for each prescription for which you are seeking
reimbursement. If you need help completing this form, contact your pharmacist. For Health Care Reform
related Over-the-Counter reimbursement requests, include your Doctor’s prescription. Please retain a
copy of the prescription for your records.
6.
Keep a copy for your records.
7.
Mail the claim form within 12 months of the prescription fill date, along with original receipts (cash register
receipts are not acceptable), to:
Cigna Pharmacy Service Center
P.O. Box 188053
Chattanooga, TN 37422-8053
8.
Questions? Please call the Cigna number located on your ID card.
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RETURN ADDRESS
IMPORTANT: PLEASE PRINT. THIS WILL APPEAR IN A WINDOW ENVELOPE FOR RETURNS.
PLEASE PROVIDE CURRENT ADDRESS INFORMATION BELOW:
PATIENT NAME
PATIENT STREET ADDRESS
PATIENT CITY, STATE, ZIP
Click Here to Print
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Caution: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or
statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact
thereto, commits a fraudulent insurance act.
IMPORTANT CLAIM NOTICE
Alaska Residents: A person who knowingly and with intent to injure, defraud or deceive an insurance company or files a claim containing false,
incomplete or misleading information may be prosecuted under state law.
Arizona Residents: For your protection, Arizona law requires the following statement to appear on/with this form. Any person who knowingly presents a
false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
California Residents: For your protection, California law requires the following to appear on/with this form. Any person who knowingly presents a 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.
Colorado Residents: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for
the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds
shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
District of Columbia Residents: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer
or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related
to a claim was provided by the applicant.
Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a 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.
Maryland Residents: Any person who knowingly OR willfully presents false or fraudulent claim for payment of a loss or benefit or who knowingly OR
willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and
civil penalties.
New Mexico Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
New York Residents: 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 shall also be subject to a civil penalty not to exceed $5000 and the stated value of the
claim for each such violation.
Oregon Residents: Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance
or statement of claim containing any materially false information; or, (2) conceals for the purpose of misleading, information concerning any material fact,
may have committed a fraudulent insurance act.
Pennsylvania Residents: 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.
Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Texas Residents: Any person who knowingly presents a 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.
Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or
files a claim containing a false or deceptive statement may have violated state law.
*"Cigna HealthCare" refers to the various HMO subsidiaries of Cigna Health Corporation. If you are enrolled in a Cigna HMO plan, complete details can be found
in your plan documents or Evidence of Coverage.
"Cigna" is a registered service mark, and the "Tree of Life" logo is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and
its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating
subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Cigna Health Management, Inc., and HMO
subsidiaries of Cigna Health Corporation.
583522i Rev. 12/2012