Filing a Claim
When you go to a network pharmacy, there's no claim to file. However, if you fill a prescription at an out-of-network pharmacy, you're responsible for paying the pharmacy in full and submitting a claim to Express Scripts. To obtain a claim form, contact Express Scripts. (See Contact Information.)
When submitting a pharmacy claim, you need to include a completed claim form, together with the original prescription receipt, containing the following information:
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patient's name;
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NCPDP number (pharmacy's number) if listed on label;
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prescription number;
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date filled;
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dollar amount;
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quantity;
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days' supply; and
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NDC number (drug code); for compounds, the ingredients and the NDC number of the highest-priced legend drug used (listed on label).
After your claim is processed, you'll receive written notice describing the approval (amount submitted, amount covered/allowed and amount of reimbursement) or the reason for denial. Payment for covered prescriptions is made directly to you. Reimbursement typically takes about 14 days. Generally, KingCareSM will not pay a claim submitted more than 12 months after the date of service or the date expenses were incurred. If you can't meet the 12-month deadline because of circumstances beyond your control, such as being legally incapacitated, the claim will be considered for payment when accompanied by a written explanation of the circumstances.
If your claim is denied, you may appeal. (For information about appeals, see " KingCareSM" in "Claims Review and Appeals Procedures" in Rules, Regulations and Administrative Information.)
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