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.
- Express Scripts members: download the form here.
- TRICARE beneficiaries: download the form here.
- Medicare Part D members: download the form here.
*Medicare Part D members: we’re sorry, but we aren’t able to process claims online at this time.