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Fill and Sign the New York Form Cc2002b

Fill and Sign the New York Form Cc2002b

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PPO Prescription Drug Retail Claims __________________________________________________________________________________________________________________ How to File a PPO Prescription Drug Retail Claim Retail prescription drug program. Express Scripts, Inc. (ESI) processes in-network claims when drug card is not used and out-of-network claims if benefits apply. Employees use a claim form to obtain reimbursement for covered medications purchased at participating and non-participating retail pharmacies. Contact your Group Office Representative to obtain this claim form or visit our website. 07/01/2005 Visit our Website at http://mutualofomaha.com 1

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