Form C-14352 - Blue Shield Of California Prescription Drug Benefit - Direct Reimbursement Claim Page 2
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2Blue Shield of California Prescription Drug Benefit*
Direct Reimbursement Claim
*Applies to outpatient prescription drug benefits available through plans underwritten by Blue Shield of California and Blue Shield of California Life & Health Insurance Company.
INSTRUCTIONS
PLEASE WAIT UNTIL YOU RECEIVE YOUR BLUE SHIELD I.D. CARD BEFORE SENDING THIS
CLAIM FOR REIMBURSEMENT. CLAIMS WITHOUT THE PROPER IDENTIFICATION NUMBER
FROM YOUR BLUE SHIELD I.D. CARD WILL NOT BE PROCESSED.
To avoid undue delay, please complete all required areas of information on the claim form.
Please be sure to copy your subscriber identification number exactly as it appears on the Blue Shield
identification card. If this is not done, the claim form will be returned to you.
® A registered mark of the Blue Shield Association
HOW TO COMPLETE THIS FORM
PART ONE
PART TWO
Subscriber Information
Pharmacy Information
1. Copy the 9 digit Subscriber Identification
1. Pharmacy name, address, and telephone
Number from the Blue Shield I.D. Card.
number where the prescription(s) were
2. Subscriber name, address, and telephone
purchased.
number.
2. Pharmacy NABP Number: Obtain the number
3. Patient Name: Person drug was prescribed
from the pharmacy where prescriptions were
for.
purchased.
4. Patient Date of Birth: Month, Day, Year.
3. Tape pharmacy receipts to the form in the
5. Patient Sex: Check Male or Female
space provided. The receipts must indicate
6. Status: Patient’s relationship to subscriber.
date of service, Rx number, NDC number,
If other, please write in type of relationship.
quantity, days supply and the amount paid.
4. Use a separate claim form for each
7. Please use separate claim form for each
family member.
pharmacy from which you purchase
prescriptions.
Note: Claim submission is not a guarantee of payment.
Reason for Claim Submission:
Submit to:
Member not eligible in system
Blue Shield
___________________
Other (explain)
Argus Health Systems, Inc.
________________________________
Member in Cobra group
PO BOX 419019, Dept. 191
________________________________
Kansas City, MO 64141
No Rx Card presented
________________________________
Pharmacy online system down
Other Reason:
Instructions:
Submit to:
Foreign Claims
Include your prescription receipt with the name
Blue Shield
of the drug(s), and state the foreign currency
c/o Pharmacy Services
used.
PO BOX 7168
San Francisco, CA 94120-7168
Vacation Supply
Fill out this form, attach the prescription receipt.
Compound
Fill in boxes at bottom of form on the other side.
C-14352 (10/03)
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