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Click ‘Get Form’ to open the Prescription Drug Claim Form - ProCare Rx in our editor.
Begin by filling out the 'Insured/Patient Information' section. Enter the cardholder's last name, first name, middle initial, and address. Ensure you include the plan name and cardholder ID number.
Provide your contact details including home and work phone numbers. Fill in the employer's address and group number if applicable.
Indicate whether there is any additional group insurance that may cover this claim by checking 'YES' or 'NO'. If applicable, provide the insurance name and group number.
In the 'Claim Information' section, list each pharmacy used for prescriptions. Include pharmacy ID, name, days supplied, NDC number, fill date, Rx number, prescriber’s name, and metric quantity for each prescription.
Complete the 'Reason for Claim Submission or Special Notes' section as needed.
Finally, sign and date the authorization section to certify that all information provided is accurate.

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