Scripius Prescription Drug Reimbursement Form

Prescription Drug Reimbursement Form

Use this form if you want to request reimbursement from Scripius for a prescription drug. Scripius will only reimburse drugs covered by your plan.

Use this form if you want to request reimbursement from Select Health for a prescription drug. Select Health will only reimburse drugs covered by your plan. To find out if a drug is covered, please call Member Services at 800–538–5038.

Member & Patient Information

Member ID Number

Member’s First Name

Member’s Last Name

Date of Birth

Patient’s First Name

Patient’s Last Name

Patient’s Date of Birth

Relationship to Member

We will send any reimbursement and/or communications to the address in our system for the member (this is usually the same address as the subscriber) unless a confidential address (e.g., address of a custodial parent) for the member is on file.
If you have listed a new address, please update your address through your employer or enrollment.

Is a different address on file?

Yes

Address

City

State

ZIP

Phone

Other Insurance Information

Does the patient have other insurance besides Select Health?

Yes

If you have additional insurance, you still need to attach the receipt from the pharmacy. If the pharmacy receipts are incomplete, you may also need to obtain an Explanation of Benefits (EOB) from your primary insurer or your pharmacy.

Insurance Company

Is this the member’s primary insurance?

Yes

Other Insurance Company Policy ID

Policyholder’s Name

Policyholder’s Date of Birth

Policyholder’s Relationship to Patient

Other Insurance BIN Number

Amount Other Carrier Paid

Did the primary insurance approve or deny the claim?

Yes

What was the reason for denial?

Claim INformation

Was the prescription purchased outside the U.S.

Yes

Did you reside outside the U.S.

Yes

Country

Currency

Was the prescription purchased because there were no 24-hour network pharmacies within a reasonable driving distance at the time of need?

Yes

Was the prescription purchased because the medication was out of stock at an accessible network pharmacy and no other network pharmacy was accessible?

Yes

Was the prescription purchased as the result of an emergency?

Yes

NDC Number

Quantity

Days Supply

Prescriber

Example of a prescription drug receipt

Upload Receipt

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Prescription Drug Reimbursement Form