To ensure timely processing of your claim, complete the reimbursement form making sure to include:

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• the original pharmacy receipt for each drug (not the register receipt) with the date the prescription was filled

• prescription number (Rx#)

• drug name and strength

• prescribing physician’s name or ID number

• pharmacy name and address

• quantity and days’ supply

• National Drug Code (NDC) number

• compound ingredient information (if applicable)

• amount paid.