Coordination of Benefits Direct Claim Form See the back for instructions. Complete all information. An incomplete form may delay your reimbursement. Member Subscriber Information See your prescription drug ID card. Group - Medical card - Document - PDFSEARCH.IO

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	Coordination of Benefits/Direct Claim Form See the back for instructions. Complete all information. An incomplete form may delay your reimbursement. Member/Subscriber Information See your prescription drug ID card. Group Add to Reading List Document Date: 2013-06-18 09:03:54 Open Document File Size: 101,05 KB Share Result on Facebook City Lexington / / Company Medication / the Express / Express Scripts / / Facility Medco Pharmacy / PHARMACY INFORMATION / Pharmacy Street Address City State Zip Telephone / The Medco Pharmacy / Pharmacy Services / / IndustryTerm fraudulent insurance act / insurance / insurance carrier / / / Position Representative / Pharmacist / / Product Compound Prescriptions / / ProvinceOrState Kentucky / California / Pennsylvania / / SocialTag Pharmacology Pharmaceuticals policy Drugs Pharmacy Clinical pharmacology Medical prescription Prescription medication Pharmacist Copayment Pharmaceutical sciences

Coordination of Benefits/Direct Claim Form See the back for instructions. Complete all information. An incomplete form may delay your reimbursement. Member/Subscriber Information See your prescription drug ID card. GroupAdd to Reading List