Form Bcbs 13177-1006r Sr - Prescription Drug Program Subscriber Claim Form Page 2

Download a blank fillable Form Bcbs 13177-1006r Sr - Prescription Drug Program Subscriber Claim Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Bcbs 13177-1006r Sr - Prescription Drug Program Subscriber Claim Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

PRESCRIPTION DRUG PROGRAM

SUBSCRIBER CLAIM FORM

SEND COMPLETED FORM & PHARMACY RECEIPTS TO:

Instructions

PRIME THERAPEUTICS LLC

(see back of form for detailed instructions)

Mail Route – BCBSFL

1. Sections I through IV – Complete sections in their entirety.

P.O. BOX 14430

2. Section V – Be sure to sign.

Lexington, KY 40512-4430

I. SUBSCRIBER INFORMATION (MUST BE COMPLETED)

SUBSCRIBER NAME

LAST

FIRST

M.I.

DATE OF BIRTH

_______________________

SUBSCRIBER ADDRESS

STREET

CITY

STATE

ZIP

SUBSCRIBER ID #

GROUP #

II. PATIENT INFORMATION (MUST BE COMPLETED)

PATIENT NAME

DATE OF BIRTH

SEX

RELATIONSHIP TO SUBSCRIBER (Check One)

PLEASE CHECK

LAST

FIRST

M.I.

DAY

YEAR

SELF

SPOUSE

CHILD

OTHER

APPROPRIATE

BOXES

Was condition related to an accident?

Yes

Accident Date __________________

■

If yes, was it related to:

Auto Accident

Worker’s Comp

Other

■

Is other insurance applicable to charge?

Yes

■

If yes, complete the information below, and attach explanation of benefits.

Other Carrier Name _______________________________________________________________________ Policy # ________________________________

Name of Subscriber _________________________________________________________________________________________________________________

III. PHARMACY INFORMATION

(

)

PHARMACY NAME _________________________________________________________________________________________________________ PHONE ___________________________________________

STREET ___________________________________________________________________________ CITY, STATE, ZIP ___________________________________________________________________________

Prescription Receipts Required for Processing

PHARMACY NABP # ________________________________________________________________

IV. PRESCRIPTION INFORMATION

DATE RX FILLED

PRESCRIPTION

BALANCE

DAYS

RX NUMBER

QUANTITY

NATIONAL DRUG CODE (NDC)

DRUG NAME

SUPPLY

COST

DUE

DAY

V. SUBSCRIBER CERTIFICATION

I Certify all information provided on this form and on the attached itemized statement to be true and correct to the best of my knowledge:

____________________

SUBSCRIBER SIGNATURE ______________________________________________________________________________________________________________________ DATE

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.

Reset

Form No. BCBS 13177-1006R SR