Pharmacy Claim Form - University of Miami 2025

1. Click ‘Get Form’ to open the Pharmacy Claim Form in the editor.
2. Begin by entering your Aetna Member Number and Group Number at the top of the form. This information is crucial for processing your claim.
3. Fill in your personal details, including your name, birthdate, address, and contact number. Ensure all fields are completed accurately.
4. Indicate whether the prescription was for you, your spouse, or a dependent by filling in their name and birthdate.
5. For each prescription filled, provide the date filled, Rx number, medication details (name, strength), and quantity. Attach detailed receipts as required.
6. Complete the pharmacy information section with the pharmacy's name, address, NABP number, and pharmacist's signature.
7. Review all entered information for accuracy before submitting. Incomplete forms may be returned.

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