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Click ‘Get Form’ to open the Compound Claim Form - Navitus in the editor.
Begin with Part 1: Member Information. Fill in all required fields, including your ID Number, which can be found on your member ID card. Ensure you provide accurate contact details and select your gender.
Proceed to Part 2: Pharmacy Information. Complete all sections for each pharmacy where medications were purchased. Include the pharmacy's name, address, and National Provider Number.
In Part 3: Receipt Information, attach original pharmacy receipts or printouts. Make sure they include all necessary details as outlined in this section. Tape them securely to an additional page without stapling.
Review your completed form for accuracy and ensure all required signatures are present before submitting it via mail or fax as indicated at the bottom of the form.
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Apr 1, 2014 Providers can submit claim adjustments via the Portal. Providers may use the search function to find the specific claim to adjust.Read more
Sep 9, 2009 Compound drugs must be submitted using the Navitus. Compound Drug Claim Form. NOTE: Reimbursement will be made directly to the CARDHOLDERRead more
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