Take a clear picture of the medication package with
the full prescription label visible.
(The picture should clearly display the product name,
the RX ID, and the NDC (a 10-digit number)).
Take a clear picture of the pharmacy payment
receipt.
The picture should clearly display the date of fill and
the total dollar amount paid for the fill.
Take a clear picture of the Explanation of Benefits (EOB), provided by the insurance company.
The picture should clearly display the total dollar amount charged for the fill,
what the insurance has paid towards the fill, and what the patient responsibility is.
Upload all documents to the claim before submitting
The following picture formats are accepted; JPEG, BMP, GIF, JFP, PDF, PNG, and TIFF
Claims are only reimbursable within 180 days of the prescription fill and payment date.
