Submit a Prescription Reimbursement Claim Form

Now, there are two ways to submit a claim form:

Complete and submit the form online. It's a secure and quick way to submit your claim. Log in to get started.*


Download the form and mail it to us. Follow these links or log in to find the form.

*Medicare Part D members and TRICARE beneficiaries: we’re sorry, but we aren’t able to process claims online at this time.

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