Claim Form Instructions

For Part D-Covered Vaccinations

Use the following instructions when filling out the RxBLUE Claim Form:

• Attach the invoice from your physician
• Include the following information:
• Drug name
• Drug strength
• Quantity
• Drug cost
• Administration fee
• NDC number
• Date of service
• Be sure to list the drug cost and administration fee separately

S5937
Pending CMS Approval
Page Last Updated: 12:00 am on 10.01.2010