Now, there are two ways to submit a claim form: Complete and submit the form online. It's a secure and quick way to submit your claim. Log in to get started. or Download the form and mail it to us. Follow …

By completing this form, I recognize that reimbursement will be paid directly to me and that assignment of these benefits to a pharmacy or any other party is void.*

If the primary plan is home delivery, complete this form and attach either the prescription receipt(s) that shows the copayment or coinsurance amount paid to the home delivery pharmacy or the statement …

By completing this form, I recognize that reimbursement will be paid directly to me and that assignment of these benefits to a pharmacy or any other party is void.*

Just complete this form and attach the prescription receipt(s) that shows the copayment or coinsurance amount paid at the pharmacy. The receipt(s) will serve as the EOB.

Print Pharmacy name and address and the prescribing Doctor and DEA number used by each patient. Answer each question by checking correct box. Use the space provided for special notes if necessary.

SECTION C - PRESCRIPTION INFORMATION: IMPORTANT: Submit either prescription receipts/labels with this claim form or a patient history print-out from your pharmacy.

Just complete this form and attach the prescription receipt(s) that shows the co-payment or coinsurance amount paid at the pharmacy. The receipt(s) will serve as the EOB.

Use this form when you have paid full price for a prescription drug at a retail pharmacy or need to submit claims under Coordination of Benefits rules:

Only use this claim form when you have paid full price for a prescription drug order at a pharmacy because: The pharmacy does not accept your Express Scripts prescription drug ID card, or You have …