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Prescription Drug Information

To submit a claim for reimbursement regarding a prescription that you paid for out of pocket, please print a copy of the Prescription Claim Form.

Prescription Claim Information Check List

   Information and Documents    Directions
  • Prescription Reimbursement Claim Form
  • Date prescription filled
  • Name and address of pharmacy
  • Doctor name or ID number
  • NDC number (drug number)
  • Name of drug and strength
  • Quantity and days’ supply
  • Prescription number (Rx number)
  • DAW (Dispense As Written)
  • Amount paid
  • Clip, do not staple, all bills to the completed form.
  • Make sure all bills or itemized receipts indicate:
    • A diagnosis code
    • Procedure code
    • Date of service
    • Cost
    • The provider’s tax ID number.
  • Mail To:

    P. O. Box 809025
    Dallas, TX 75380
  • Fax to
    • 469-229-5625

This information can usually be found on the receipt which is stapled on the outside of the packaging or in some cases located inside. Contact your pharmacist for more information.