Prescription Drug Claim Form

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

Date prescription was received*

Name of person requesting reimbursement*

Your relationship to member

Phone number*

Member name*

ID number*

Reason for reimbursement*

Date of purchase*

Amount paid*

Note: Reimbursement amount will be equal to amount paid minus any applicable copays

Pharmacy name*

Pharmacy phone number*

Pharmacy address*

Street Address City State / Province / Region ZIP / Postal Code Country

Provider name*

Provider phone number*

File*

Max. file size: 50 MB.

Please upload photos of receipts or pharmacy labels here.

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