Drug claim form instructions (non-Medicare)
Use the Coordination of Benefits/Direct Claim Form to request reimbursement for a covered prescription drug when one of the following applies:
- You have only one prescription drug plan, and you paid in full for the drug.
- You have more than one prescription drug plan, you have already received a statement of payment from the primary plan’s insurance carrier, and HMSA is your secondary drug-plan carrier.
Follow the instructions below when completing the form for non-Medicare drug claims. Use these instructions instead of the instructions printed on the form. You must complete a separate claim form for each pharmacy and for each patient. (To print these instructions, click the printer icon located on the top right of this page.)
Member/Subscriber Information
- Enter the Group Number, Subscriber Number and Subscriber Name as they appear on your HMSA membership card. The Group Number begins with HMSA. For example, HMSA01 or HMSAQST.
- Enter your current address.
Patient Information
- Enter the patient’s Name, Date of Birth, and Sex.
- Check the Self, Spouse or Eligible Child box in the Relationship to Plan Member section.
Do not check any of the other relationship boxes.
Pharmacy Information
- Enter the pharmacy name, address and telephone number. This information should be on your receipt from the pharmacy.
- The signature of the pharmacist or a pharmacy representative is not required.
Claim Receipts
- Check each box that applies.
- If the medication is a compound prescription, ask your pharmacy to complete the Compound Prescription section on the back of the form.
- Tape the receipt to the back of the claim form. If you have more than one receipt, tape the first two receipts to the back of the form. Tape additional receipts to a separate sheet of paper.
- The receipt that you tape to the form must contain the claim receipt information listed on the back of the form. The detailed prescription receipt is provided to you by the pharmacy when you purchase your medication.
Coordination of Benefits
- If you have more than one prescription drug plan, and the primary plan already paid part of the cost of the drug(s), check Yes and Another Health Plan paid. Also, if the drug was purchased from Medco’s mail-order pharmacy, check The Medco Pharmacy mail order.
Important: The primary plan’s insurance carrier will provide you with a statement showing how much that carrier paid for the drug(s). Include a copy of that statement with your claim.
- If you have only one prescription drug plan, check No.
Acknowledgment
- Include both your signature and the date you signed the form.
Submitting the claim form
- To consider reimbursement, Medco must receive your claim within one year of the date of purchase of the drug(s).
- Keep a copy of the form and receipt(s) for your records.
- Send the completed form to Medco Health Solutions at the address listed on the back of the claim form.
Questions about your claim or your HMSA prescription drug coverage
- If you need assistance in completing the claim form, would like to check the status of a claim you already submitted, or have questions about your HMSA drug coverage, call a customer service representative. When you call, please listen to the recorded greeting and select the drug option when prompted.
- Representatives are available to serve you 24 hours a day, seven days a week.
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