Prescription Drug Claim Form

Instructions for completing this form.

For FEP members please go to FEPBlue.org.

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* Required Field

Enter Patient Information

  •  
  • We're unable to prepopulate the below information using ID you entered.
  •  
  • Certificate Number:*
  • - -
  • Patient First Name:*
  • Patient Middle Initial:
  • Patient Last Name:*
  • Date of Birth:*
  • Patient Sex:*
  • Male Female
  • Patient's Relationship to Employee:*
  • Self Spouse Child Other

Enter Employee/Policyholder Information

  • Group ID:*
  • Group Name:
  • Employee First Name:*
  • Employee Middle Initial:
  • Employee Last Name:*
  • Employee Street Address:
  • Employee City:
  • Employee State:
  • Employee Zip Code:
  • Employee Phone Number:*
  • Enter a 10 digit phone number.
  • Employee Email Address:

* Required Field

Enter Pharmacy Information

  • Is the pharmacy a Blue Cross Blue Shield enrolled pharmacy?*
  • Yes No
  • Pharmacy NABP/NPI Number:*
  • Pharmacy Name:*
  • Pharmacy Street Address:*
  • Pharmacy City:*
  • Pharmacy State:*
  • Pharmacy Zip Code:*
  • Contact Number:
  • Enter a 10 digit phone number.
  • Contact Phone Ext:

If other coverages apply, please check the appropriate box. If no other coverage, check "None".

  • Group (or group type) plan
  • Group name:
  • Group address:
  • Group number:
  • Worker's Compensation
  • Medicare or Medicaid
  • Medicare or Medicaid number:
  • Other
  • Group or other coverage name:
  • Group or other coverage address:
  • Group or other coverage number:
  • None

Enter Claim Information

Please obtain the information for this portion of the claim form from your Pharmacist or simply attach your itemized bills. We cannot process this claim without this information. Keep copies of all bills for your records.

Rx Number Date Filled Check One Quantity Days Supply Doctor's ID DAW Rx Price For Blue Cross
Blue Shield Use
 
New
Refill
Yes
No
Medication Name Dosage Form & Strength
Manufacturer Name
NDC Number

Please attach your itemized bills*

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.







I certify that the above information is correct and that the above person is eligible for benefits. I have received the medication described hereon and authorize release of all information contained in this voucher to Blue Cross Blue Shield and the underwriter.

I agree that any benefits payable hereunder for medications are not assignable and that any assignment or attempted assignment thereof shall be void. I further represent that there has been no assignment of benefits hereunder.

  • Checking this box will send a copy of your form to the email address provided.

If you experience issues submitting this form, please print and fax it to:

(816) 395-2291

Or mail to:

Blue Cross Blue Shield of Kansas City
Pharmacy Services
PO Box 412735
Kansas City, MO 64141-2735

Cancel

Member Prefix

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

ID Number

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Suffix

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

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