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