Download the Form Below
Prescription Reimbursement
Receive Your Reimbursement
Follow the steps below to receive your prescription reimbursement.
Complete the Form
Complete the form on your computer or print it out and print clearly and legibly. Complete all applicable fields. Please note, you may only use one form per claim.
Download the Form
Receive the Maximum Benefit
Use a participating pharmacy to receive the maximum benefit. Your pharmacist can provide you with the most cost-effective options for your prescription.
Mail the Form
Mail the completed form with a copy of your receipt. Your request will be processed, and a response provided in approximately 4-6 weeks.
Download the Form and Mail
Click the link below to download and print the reimbursement form. Mail the completed form and your receipt to the address on the form.
