Prescription Drug Program Direct Member Reimbursement Form

Complete and return this form when you have purchased a covered prescribed prescription drug at retail cost and are seeking reimbursement.

Claims will be subject to limitations, exclusions and other provisions of the Plan Benefit.

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* Required Field

Patient Information (one form per patient)
We're unable to prepopulate the below information using ID you entered.
Health Plan (Insurance) Name
Date of Birth:*
I.D. Number
First Name:*
M.I.:
Last Name: *

Street Address:
City:
State:
Zip Code:
Prescribing Physician's Name
Physician's Telephone Number:
Provider ID:

Reason for Request *

At least one must be checked

Out of Area emergency medication
Non-emergency medication/vaccination request
Non identification card or identification number available
Other:
Compound medication
Member not found in pharmacy system
Coordination of Benefits (From Primary Insurance - complete section below)

Coordination of Benefits

(If your primary insurance has already paid for the attached prescription, please complete this section.)

Primary Health Plan/Insurance Company Name:

Primary Member/Subscriber ID:*

Group ID:*

Primary Member/Subscriber's Name (Last Name, First Name, MI):*

Member's/Subscriber's Signature

I certify that the patient for whom this claim is made is a covered person in this Prescription Drug Program and that the prescription is for the sole use of the named patient. I also certify that the claim(s) being submitted for payment are not eligible for payment under a no-fault automobile or workers compensation insurance program. I also authorize release of all information pertaining to this claim(s) to the plan administrator, underwriter, sponsored policy holder and/or employer.

Signature: *
Date: *

Special Instructions:

Prescription Label receipt must have the following information clearly legible or reimbursement could be delayed or denied.

Pharmacy Name
Prescription number and date filled
Drug name, strength and quantity
Member paid expense
Prescribing physician's name

Submit this form with the original prescription label receipt(s). Cash register and credit card receipts alone are not acceptable as proof of purchase. Reimbursement is not guaranteed. *

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.

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

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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.

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.

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.