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MS#ឱ\Z™m#xzp~YzyU9BC*oJp?D!н Į ]..k/5))PAQ~ȊW{pM]JzuKGN "E)RH"E)RH"E)RH"E)RH"E)RH"E)RH"E)RH"E)RHqR<n_3 A@@  ://:Prescription Drug Program Direct Member Reimbursement FormMember Information Employer Name Group Name Group Number#Member Name (Last Name, First Name)Member I.D. NumberDaytime Phone Number&Patient's Name (Last Name, First Name) Patient's SexMaleFemaleSelfSpouseChildOther!Relationship of Patient to Member Date of BirthMailing Address of MemberNumber and StreetCityStateZip{I certify that the patitent for whom this clain is made is a covered person in this prescription drug program and that the 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."(Member/Authorized Representative)PLEASE READ ALL INSTRUCTIONS0IMPORTANT INFORMATION ABOUT YOUR SUBMITTED CLAIM8" Will only reimburse at the retail day supply allowanceq" Will only be reimbursed for medications covered under the plan or medications that already have been authorizedo" Submit this form for reimbursement because it was necessary to purchase a prescription when you did not have your identification card or because the pharmacy where your prescription was filled is a non-participating pharmacy. (Plan specific, please check individual plans). 1 (Plan specific, please check individual plans).0" Submit a separate claim form for each patient.q" Submit this form as soon as you have your prescription(s) filled. Cliams may not be reimbursed after one year.m" Claim forms submitted without the required information will cause payment delays or may be returned to you.q" If you have any questions or concerns regarding your claim, please call the toll-free telephone number on your # prescription identification card.FOR COMPOUND PRESCRIPTIONS ONLYoIf your pharmacist tells you this is a coumpunded prescription, have your pharmacise complete the area below. TShould you have more than two compounded prescriptions, please use additional forms.Claim#NDC# PRIVACY NOTICE: We will use the address provided above to send your reimbursement, even if contrary to any confidential communications insturctions you may have on file with PharmaCare. If you desire this reimbursement to be sent to a confidential address that has previously been communicated to PharmaCare, please indicate that address on this form. In any case, the address that you provide here will be used only for mailings related to this Direct Member Reimbursement.NWe will only accept a FULL PRINTOUT (a full printout with name of medications(s), quantity, days supply, strength, NDC number, date and pharmarcy information) from the pharmacist, or the ORIGINAL ATTACHED RECEIPT that was on your medication bag at time of purchase. The cash register receipt is NOT satisfactory evidence of purchase.(+This form and FULL PHARMACY PRINTOUT or this form and the ORIGINAL ATTACHED RECEIPT(S) must be mailed to: PharmaCare P.O. Box 2860 Pittsburgh, PA 15230-2860hO Compound Ingredients Drug Names Qty Cost 2SB #CCEE<I-M ( ;\],kv  dMbP?_*+% &R&8DMR 9/05&?'?(?)?M Xerox Phaser 6250DT tech officC odXXLetterDINU"4p5^;pXORXHWaterMarkHelvetica"dXX??cU} }  m} } m} } } m} } m} } m} } } m} m} I} #m} $$ ;&@@@@@@@@@ @ @   i@@ i@@h@"" @B @B  !!!!! 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