Pharmacy-Related Forms

Direct Claim Form
Instructions:  Participating pharmacies will generally bill Express Scripts, Inc. for you.  In the event you have paid for your medication and need to submit a claim to Express Scripts Inc, please follow the directions below:

1. To submit a direct claim, download the Prescription Drug Reimbursement/Coordination of Benefits Claim Form below and fill in the requested information.  Be sure to include your WSHIP ID Number and Rx Group Number (shown on your WSHIP ID card).
2. Tape up to two prescription receipts directly onto the back of the claim form. Tape additional prescription receipts onto a separate piece of paper.  Be sure that each prescription receipt contains all of the information indicated on the claim form. If necessary, contact your pharmacy for copies of your receipts.  (Note: You must submit separate claim forms for each pharmacy that you used. Please make copies of this claim form if you need more than one.)
3. Mail the completed direct claim form with your receipts to the address on the form.

Prescription Drug Reimbursement/Coordination of Benefits/Claim Form

Mail Order Form

Instructions:  To get started using mail order, download the Express Scripts Inc By Mail order form below and fill it out completely. 

1. Be sure to fill in your WSHIP ID Number and Rx Group Number (shown on your WSHIP ID card), shipping address and patient information. 
2. You can pay for your copay(s) by check, credit card or Express Scripts, Inc. can send you a bill.  For full details on payment options please contact Express Scripts Inc Member Services at 1-800-859-8810.  
3. Include your prescription along with the form and send it to the address indicated. If you need your medication right away, also ask your doctor for a 14-day prescription to fill at a participating retail pharmacy so you will not run out before your order arrives from Express Scripts Inc By Mail.

Download Express Scripts Inc By Mail Order Form

Learn more about Express Scripts Inc By Mail.

Health, Allergy & Medication Questionnaire
Instructions:  If you’ve never completed and sent in a Health, Allergy & Medication Questionnaire, please do so now.  Just download the form below, then fill it out and send it to Express Scripts Inc.  Having this information on hand will enable our Express Scripts Inc’s pharmacists to help protect you against possible drug-to-drug interactions and allergic reactions.