Claim Status Request

Complete this form to check on the status of a claim. Please allow 1 business day for a response. When more than 10 requests for claim status are submitted, an investigation fee may apply.

All fields are required unless otherwise noted.

Seven-Digit NCPDP Number:
Contact Name:
Member ID Number:
Member Name:
Prescription Number:
Date of Fill:
Phone Number:
Fax Number (optional):
E-mail Address (optional):
Comments: