Some pharmacies may not accept the Cystic Fibrosis Patient Assistance Foundation (CFPAF) benefit card. In these instances, we encourage pharmacies to file claims manually to WellDyne for direct reimbursement.
You can call WellDyne for help filing your claim. In addition, if your preferred pharmacy does not currently participate in the CFPAF network, it can contact our claims administrator, Welldyne, and ask to join the network.
Please determine if your pharmacy of choice is listed in the Pharmacy Locator before completing and sending the claim form. For support or assistance, Contact WellDyne.
Use this form to be reimbursed for each prescription that you purchased without your co-pay assistance card.
INSTRUCTIONS:
1. Fill out all of the information on the claim form as completely as possible.
2.Please complete a separate claim form for each family member.
3. Provide an original receipt/ invoice with prescription details from your pharmacy. The pharmacy receipt should include date of service, drug(s) dispensed and remaining balance. If the patient has paid the pharmacy for a specific product and needs to be reimbursed directly, proof of payment to the pharmacy must be submitted via statement of payment from the pharmacy. Proof must indicate date of service and date of payment for product to be reimbursed. Cash register tapes will not be accepted for details necessary to process reimbursement. Copies will be accepted by fax.
4. If necessary, contact the pharmacy to provide the detailed drug information requested on this form for the prescription(s) to be reimbursed.
5. Please provide the complete name, address and telephone number of the pharmacy. Should you or the pharmacist have questions regarding the completion of this form, please call our toll-free number (888) 479-2000.
6. You may fax the completed form and receipts to (863) 393-0079, or mail the completed form and original receipts directly to:
WELLDYNERX ATTN: MANUAL CLAIMS DEPARTMENT PO BOX 90369 LAKELAND, FL 33804
7. You will receive a response within 30 days.
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