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(Rev. 01/2014) Prescription Drug Claim Form Instructions Alert! Please read the following instructions carefully before completing this form. Claim forms with missing information cannot be processed and will be returned to the sender. Part 1: Member information 1. Complete all information in Part 1. The enrollee ID number is located on your health plan ID card. 2. A claim should be submitted to Moda Health within 90 days of the date the expense was incurred. Under no circumstances will claims submitted later than one year from that date be considered valid, except in the case of legal incapacity. Payment and related correspondence will be sent to the primary subscriber unless you have made arrangements with Moda Health to send to an alternate address. Please submit a separate claim form for each patient and pharmacy from which you purchase medications. Part 2: Pharmacy information (to be completed by the pharmacy) 1. If required information is not available on the prescription receipt, ask your pharmacy representative to complete Part 2 and Part 3. 2. Remember to keep a copy of the completed claim form and receipt(s) for your records. 3. Send the completed form and receipt(s) to: Moda Health P.O. Box 40168 Portland, OR 97240‐0168 Fax: 800‐207‐8235 ATTN: Rx Claims Department Part 3: Receipt information Please note that a prescription receipt is separate from your pharmacy cash register receipt. Submit detailed prescription receipts or labels that contain the requested information (shown below), or have your pharmacy representative complete Part 2 and Part 3. If you do not submit a detailed prescription receipt for your prescription(s), a pharmacist signature is required. 1. Include a copy of your prescription receipt(s) along with your claim form. Note: Please do not staple receipts or other documentation to the claim form. 2. If you have more than one claim, submit a separate Part 3 for each medication or use the multiple prescription form on page 3. 3. Compounded medications require a separate Compound Claim Form. Use the Compound Claim Form on page 4 if you did not receive one from the pharmacy that filled your compounded prescription. 4. Receipts for medication purchased outside the U.S. must be translated into English and include conversion of currency into U.S. dollars. You also must include the required prescription and pharmacy information as indicated below. ---PAGE BREAK--- PRESCRIPTION AND PHARMACY INFORMATION Prescription receipt/label example: Please use this example for help locating the required information. Note: Each pharmacy may have a unique label format. Anytime Pharmacy #1234 (509) 555‐1234 123 Any Street * Store NPI: [PHONE REDACTED] Home Town, US 12345‐6789 RX 1234567 (3)Date Filled: 1/1/2009 (1)DOE, JANE (2)DOB: 01/01/1900 456 Home Road (509) 555‐5678 Home Town, US 12345 Amoxicillin 500 mg capsules (Teva) DAW: 0 00000‐1111‐22 (4)QTY: 45 (5)Days Supply: 30 (8)U&C: 200.00 (9)COPAY: 20.00 1. Patient name* 2. Patient date of birth* 3. Date filled* 4. Quantity* 5. Day supply* 6. National drug code (NDC)* 7. Medication name and strength* 8. Usual and customary price (U&C)/RX price* 9. Copay* 10. Pharmacy NPI or NABP number* *REQUIRED INFORMATION—CLAIM WILL BE RETURNED IF THIS INFORMATION IS NOT SUPPLIED. Prescription Drug Claim Form PART 1 *Indicates required information Member ID number* Group number: 10008217 Group/employer name: Uniform Medical Plan Primary subscriber name* Subscriber date of birth: (mm/dd/yyyy)* / / Member name: (first, middle, last)* Date of birth: (mm/dd/yyyy)* / / Relationship to primary subscriber Self Spouse Dependent Domestic partner Address: (Street, City, State, ZIP code) Does this member have prescription coverage under any other group health plan? Yes No If yes, provide the name of the health plan company and other employer I certify that the information on this claim form is true and correct to the best of my knowledge. I authorize the release of any medical information necessary to process this claim. Member signature* Telephone number ( ) Date SIGN ---PAGE BREAK--- Indicate reasons for filing a claim(s)*: Coordination of benefits other than Medicare—claims must be submitted with pharmacy receipt(s) identifying copays paid and an Explanation of Benefits from the primary carrier (or prescription history from the pharmacy showing primary health plan payment) Medicare is primary prescription coverage Discount card was used Health plan, health coverage information or health plan ID card was not available at the time of purchase Pharmacy not participating in network Pharmacy unable to process claim electronically Emergency—please explain Worker’s compensation Prescription purchased outside the U.S. Please see claim instructions on previous page. Other Submission of claims does not guarantee reimbursement. Alert! Non‐duplication of benefits ensure that, in total, dependents with dual coverage receive benefits up to what they would have received if Uniform Medical Plan was their only source of coverage (but not in excess of that amount). Non‐duplication of benefits does not apply for individuals with Medicare as the primary plan. PART 2 Affix pharmacy label here or enter the required information: Pharmacy name* Pharmacy telephone number Street address NPI*or NABP number City State Zip Pharmacy representative signature* Date* PART 3 RX number Date filled* / / New Refill (check one) Quantity* Day supply* National drug code (11‐digit)* Medication name and strength* Physician name and NPI number Name: NPI: RX price* $ Vaccine admin fee $ Copay* $ SIGN ---PAGE BREAK--- RX number Date filled* / / New Refill (check one) Quantity* Day supply* National drug code (11‐digit)* Medication name and strength* Physician name and NPI number Name: NPI: RX price* $ Vaccine admin fee $ Copay* $ RX number Date filled* / / New Refill (check one) Quantity* Day supply* National drug code (11‐digit)* Medication name and strength* Physician name and NPI number Name: NPI: RX price* $ Vaccine admin fee $ Copay* $ RX number Date filled* / / New Refill (check one) Quantity* Day supply* National drug code (11‐digit)* Medication name and strength* Physician name and NPI number Name: NPI: RX price* $ Vaccine admin fee $ Copay* $ RX number Date filled* / / New Refill (check one) Quantity* Day supply* National drug code (11‐digit)* Medication name and strength* Physician name and NPI number Name: NPI: RX price* $ Vaccine admin fee $ Copay* $ RX number Date filled* / / New Refill (check one) Quantity* Day supply* National drug code (11‐digit)* Medication name and strength* Physician name and NPI number Name: NPI: RX price* $ Vaccine admin fee $ Copay* $ RX number Date filled* / / New Refill (check one) Quantity* Day supply* National drug code (11‐digit)* Medication name and strength* Physician name and NPI number Name: NPI: RX price* $ Vaccine admin fee $ Copay* $ RX number Date filled* / / New Refill (check one) Quantity* Day supply* National drug code (11‐digit)* Medication name and strength* Physician name and NPI number Name: NPI: RX price* $ Vaccine admin fee $ Copay* $ ---PAGE BREAK--- Prescription Drug Claim Form For compounded prescriptions only A completed Part 1 of the Prescription Drug Claim Form and pharmacy receipts* must accompany this compounded prescription form. For Pharmacy use only Enter the NDC number of all ingredients used. Indicate the drug ingredient(s) and quantity. Indicate the metric quantity dispensed in number of tablets, grams, or mls for liquids, creams, ointments, and injectables. Indicate the amount paid for the prescriptions by the patient. All plan provisions apply to compounded medications. COMPOUNDED PRESCRIPTION CHART NDC # Drug ingredient Quantity Charge Note: If purchased in a foreign country, the currency must be converted into U.S. dollars. Total $ Affix pharmacy label here or enter the required information: Pharmacy name* Pharmacy telephone number Street address NPI* City State ZIP Pharmacy representative signature* Date* Important: The original Pharmacy prescription label/receipt (including the required drug information) must accompany this claim form. Please do not highlight receipts or items on this form as this will not show on scanned images and may cause a delay in the processing of your claim. Pharmacy receipts will not be returned, it is recommended that you make copies for your own records. Send the completed form and receipt(s) to: Moda Health Prescription Claims P.O. Box 40168 Portland, OR 97240‐0168 SIGN