Prescription Reimbursement Claim Form
Always allow up to 30 days from the time you receive the response to allow for mail time plus claims processing.
Keep a copy of all documents submitted for your records.
Do not staple or tape receipts or attachments to this form.
Reimbursement is not guaranteed and other contractor will review the claims subject to limitations, exclusions
and provisions of the plan.
Card Holder/Patient Information This section must be fully completed to ensure proper reimbursement of your claim.
Card Holder Information
Identication Number (refer to your prescription card) Group No./Group Name
Name (Last Name) (First Name)
City State Zip
Patient Information–Use a separate claim form for each patient.
Name (Last Name)
Date of Birth Male Female Phone Number
Relationship to Primary member
Other Insurance Information
COB (Coordination of Benets)
Are any of these medicines being taken for an on-the-job injury? Yes No
Is the medicine covered under any other group insurance? Yes No
If yes, is other coverage: Primary Secondary
If other coverage is Primary, include the explanation of benets (EOB) with this form.
Name of Insurance Company____________________________ ID#________________________
Important! A signature is REQUIRED
Any person who knowingly and with intent to defraud, injure, or deceive any insurance company, submits a claim or application containing any
materially false, deceptive, incomplete or misleading information pertaining to such claim may be committing a fraudulent insurance act which is a
crime and may subject such person to criminal or civil penalties, including nes, denial of benets, and/or imprisonment.
I certify that I (or my eligible dependent) have received the medicine described herein. I certify that I have read and understood this form, and that all
the information entered on this form is true and correct.
Signature of Plan Participant