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Revised January, 2010 CONFIDENTIAL AND PROPRIETARY - page 14 / 31

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14 / 31

CONFIDENTIAL AND PROPRIETARY

Claims information submitted in any manner other than the procedure described above may be subject to loss, processing delays, or rejection. To assure receipt by the proper department, the following address should be used when mailing claims information:

Walgreens Health Initiatives Attn: Claims Department PO Box 545, Mail Stop 4355 Deerfield, IL 60015

Customer Care Center Phone: 800-207-2568

Sample of Universal Claim Form Below

Note: Upon release, new versions of the UCF will be accepted. The following information applies to the UCF.

1. 2.

Group No. - group number designated on the ID card. Cardholder ID No. - subscriber ID number from the Prescription Drug Benefit

Card. IMPORTANT:

Please include the complete ID number, which may include

3. 4. 5.

a suffix at the end of the subscriber’s ID. Cardholder Name - Member’s name from the Prescription Drug Benefit Card. Name - The name of the pharmacy submitting the claim. Pharmacy No. - NPI number of the pharmacy submitting the claim. If you do not know your NPI number, it can be obtained by calling the National

6.

7.

Council of Prescription Drug Programs (NCPDP) at 480-477-1000. Patient Name - patient’s full name should correspond to ID card and prescription order. Date of Birth - birth date of patient (MMDDYYYY).

Walgreens Health Initiatives – Pharmacy Manual

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