Note: Only for services received before 10/1/03. For services received on or after 10/1/03, use the CIGNA Claim Form

1) Use this form for all providers (both in-network and out-of-network) when the Equity-League is your secondary insurance carrier.

2) The participant must fill out the section labeled "Part One-To Be Filled Out By You." The participant and the pharmacy must fill out section labeled "Part Two-Patient and Pharmacy Information."
If the primary plan is a Prescription Drug Program or HMO Plan in which a copayment of coinsurance is paid at the pharmacy, then complete the form and attach the prescription receipt that shows the copayment or coinsurance amount paid at the pharmacy.
If the primary plan is a Major Medical Plan you must complete this form and submit the Explanation of Benefits from the primary carrier along with a copy of the original receipt.

3) Please mail the completed claim form to:

PAID Prescriptions, LLC
PO Box 719
Parsippany, NJ 07054-0719

4) Paid Prescriptions will then process your claim for payment. If additional information is required in order to process the claim, Paid Prescriptions will contact you. Please note that Paid Prescriptions can only make payment to the participant.