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Medicare Prescription Claim Form Template

Simplify Your Medicare Claims Process with This Efficient Template

Submitting your Medicare prescription claims can feel cumbersome and confusing. This Medicare Prescription Claim Form Template is designed to help you efficiently file for reimbursement, ensuring that you receive your medication costs in a timely manner. With this easy-to-use template, you can avoid common mistakes, reduce paperwork hassle, and keep track of your claims, all while being compliant with Medicare guidelines. Start using the live template today to streamline your reimbursement process.

Use this Template (FREE) Live Preview
Patient full name
Medicare ID number
Date of birth
Mailing address
Phone number
Email address
Relationship to patient
Self
Parent
Legal guardian
Spouse/Partner
Caregiver
Power of attorney
Other
Please Specify:
Your Medicare drug coverage type
Medicare Part D (stand-alone)
Medicare Advantage plan with drug coverage
Original Medicare only
Not sure
Other
Please Specify:
Do you have other prescription coverage in addition to Medicare?
Yes
No
Other insurer name (if applicable)
Claim type
Request reimbursement to me
Request reimbursement to pharmacy
Coordination of benefits
Appeal or resubmission
Other
Please Specify:
Prior authorization number (if applicable)
Was this medication purchased out of pocket?
Yes
No
Drug name
Date filled
Quantity dispensed
Days supply
New prescription or refill
New prescription
Refill
Not sure
Total amount you paid
National Drug Code (NDC), if known
Primary reason for submitting this claim
Pharmacy did not accept plan
Did not have plan ID card at time of purchase
Out-of-network pharmacy
Emergency/after-hours fill
Vaccination or vaccine administration
Mail order delay or issue
Other
Please Specify:
Pharmacy name
Pharmacy phone number
Prescriber full name
How will you provide itemized receipt(s)?
Secure upload via portal
Email
Mail
Fax
Already submitted
Not applicable
Reimburse to
Patient/member
Pharmacy
Other authorized payee
No reimbursement requested
Payee name (if not the patient)
I certify that the information provided is true and complete to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
Signature of patient or authorized representative
Signature date
I authorize the plan to obtain, use, and disclose information as needed to process this claim.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration depicting a Medicare prescription claim form for FormCreatorAI article.

When to use this form

Use this Medicare claim form when you paid out of pocket for a Part D-covered drug and the pharmacy did not or could not bill your plan. Examples include filling a prescription while traveling at an out-of-network pharmacy, a failed electronic submission, or using a discount card and now seeking reimbursement. Caregivers and billing teams can file on a member's behalf to recover costs and keep records clear. If you are unsure a drug is covered, start with the Medical coverage inquiry form. For medical services or supplies billed under medical benefits (not Part D drugs), use the Health insurance claim form. With the right details, you get faster reimbursement and fewer back-and-forths.

Must Ask Medicare Prescription Claim Questions

  1. What is your Medicare Beneficiary Identifier (MBI) and date of birth?

    These confirm your identity and match the request to the correct member and benefit year. Accurate member data prevents delays from mismatched records and helps verify Part D eligibility.

  2. Which pharmacy dispensed the medication, and what was the fill date?

    The pharmacy details and date let us validate network status and pricing on that day. This helps calculate the correct reimbursement and spot duplicate claims.

  3. What medication did you purchase (drug name, strength, NDC), and how many units?

    Specifics tie your receipt to a covered product and quantity. They also confirm dosing and ensure we apply the right tier or formulary rules.

  4. Why are you submitting this claim yourself (paid cash, out-of-network, coordination of benefits)?

    Your reason points us to the right process and documents, such as proof of payment or prior authorization. Clear context reduces rework and speeds up review.

  5. How much did you pay, and can you upload an itemized receipt and Rx label?

    Proof of payment and itemization let us confirm drug, quantity, and your out-of-pocket cost. If you are filing for a non-Medicare or employer plan purchase, use the Medical reimbursement claim form.

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