Prescription Drug Program Direct Member Reimbursement Form

Complete and return this form when you have purchased a covered prescribed prescription drug at retail cost and are seeking reimbursement.

Claims will be subject to limitations, exclusions and other provisions of the Plan Benefit.

* Required Field

Patient Information (one form per patient)

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• We're unable to prepopulate the below information using ID you entered.

Reason for Request *

At least one must be checked

• Out of Area emergency medication
• Non-emergency medication/vaccination request
• Non identification card or identification number available
• Other:
• Compound medication
• Member not found in pharmacy system
• Coordination of Benefits (From Primary Insurance - complete section below)

Coordination of Benefits

(If your primary insurance has already paid for the attached prescription, please complete this section.)

Member's/Subscriber's Signature

I certify that the patient for whom this claim is made is a covered person in this Prescription Drug Program and that the prescription is for the sole use of the named patient. I also certify that the claim(s) being submitted for payment are not eligible for payment under a no-fault automobile or workers compensation insurance program. I also authorize release of all information pertaining to this claim(s) to the plan administrator, underwriter, sponsored policy holder and/or employer.

• Signature: *
• Date: *

Special Instructions:

Prescription Label receipt must have the following information clearly legible or reimbursement could be delayed or denied.

• Pharmacy Name
• Prescription number and date filled
• Drug name, strength and quantity
• Member paid expense
• Prescribing physician's name

Submit this form with the original prescription label receipt(s). Cash register and credit card receipts alone are not acceptable as proof of purchase. Reimbursement is not guaranteed. *

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

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