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Express scripts dd 2642 Form: What You Should Know

The information on this form is confidential and will not be shared with your health plan or prescription drug network. Paying Pharmacist Claim — TRI CARE Nov 14, 2024 — Submit DD Form 2642, along with form for submitting prescription claim reimbursement payment to Express Scripts. • If you are paying the claim, submit the following information with the DD Form 2642: • Prescription and pharmacy claim receipt (you can find them here on the U.S. Food and Drug Administration website). • Your name, address, date of birth and mailing address. Please include your phone number or fax number; your employer; and your current insurance information (if you are self-insured). • Your health plan ID# and your prescription drug plan ID#. • Your Social Security or individual income tax identification number. • Your date of birth. • Your phone number. · You need to indicate that you have sent your health plan or prescription drug plan number to the pharmacy through pharmacy benefit manager (IBM) or health maintenance organization (HMO) to complete the claim. · You will send these forms only if you have been referred to a health plan or HMO by your pharmacist or if you are paying out of pocket because you are losing coverage. · You need to indicate that the pharmacy is your “health care pharmacy” (or HMO pharmacy) and that you pay the health care provider your pharmacy represents. D. PAYMENT OF ANY MEDICAL CLAIM • To pay the health care provider claim, use the Express Scripts Payment Claim Form -Patient's Request for Medical Payment (DD Form 2642) to submit the following information with your claim: • The pharmacy claims payment amount due; • The drug, medicine or other care order number or the patient's last name; • The name of the health care provider to you referred to by your pharmacist; · The name of the health plan that pays the pharmacist's claim; · The pharmacy claim number. The form is also submitted with the following information: · The name of the patient; · The claim date; · The claims' payment amount due and when the claim will be paid. The pharmacy must also complete an authorization to pay form (DD Form 2642), if you are paying the claim. · The patient must complete and mail a copy of the authorization to pay form to the health plan and/or prescription drug network.

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