Form online 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1: Cardholder Information. Fill in your identification number, group number, name, address, and date of birth clearly to ensure accurate processing.
3. Proceed to Section 2: Other Prescription Drug Coverage. If Medicare Part D is your secondary coverage, complete this section after submitting a claim to your primary insurance and include the Explanation of Benefits.
4. In Section 3: Pharmacy Information, provide details about the pharmacy where you obtained your medication. Include the pharmacy's NPI number for efficient claim processing.
5. Complete Section 4 if applicable, indicating any out-of-network purchases or circumstances that prevented you from accessing a network pharmacy.
6. If necessary, have your physician fill out Section 5: Physician Information and Section 6: Prescription Detail if you do not have a receipt.
7. Sign and date Section 7: Cardholder Signature to authorize the claim submission.
8. Finally, submit your completed form via mail or fax as indicated in Section 8.

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