Before you get started, in addition to your insurance card, you will need the following information. This information can be obtained by contacting your prescribing physician.

For Prescription Drugs:

  • Name of drug/medication
  • Strength of the drug (example 5 mg)
  • Quantity being prescribed
  • Days supply

For Medical Services:

  • Description of service
  • Start date of service
  • End date of service
  • Service code if available (HCPCS/CPT)

For Direct Member Reimbursement:

  • Up to 10 drugs with different dates of fill can be requested at one time. If you have 10 or fewer drugs, please select the Direct Member Reimbursement tab. If you have more than 10 drugs or a compound drug, please use the DMR form(C) for Commercial members or the DMR form(M) for Medicare members. When you have completed the form, please return to this page and select the Direct Member Reimbursement tab.
  • Amount paid
  • Date of fill
  • Day supply
  • Drug NDC
  • Medication name
  • Medication strength
  • Pharmacy name
  • Prescriber name
  • Proof of payment
  • Quantity
  • Reason for request
  • RX Number
Member 
Prescriber