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  • Direct Member Reimbursement Request

  • Please note:

    • Complete and accurate copies of original receipts and printed pharmacy labels for each claim must accompany this form submission. Electronic copies are acceptable.
    • Reimbursement requests will be considered only within 90 days of the prescription purchase.
    • Your claim will be reimbursed based upon your eligibility and plan benefit.
    • Reimbursement will be made to the Primary Member and will be determined based upon the amount paid less applicable benefit co-pays or deductibles.
    • Upon approval, a reimbursement check will be sent within 6-8 weeks of receipt of your request.

     

    Having trouble with this form?

    Click here to download a Reimbursement form.

  • Member Information

  •  / /

  • Prescription Information

    • Medication Claim 1 
    •  - -

    • Benefit coordination: If Prescryptive is providing secondary insurance coverage please disclose amount paid by your primary insurance and include receipt or denial letter from your primary insurance carrier.

    • Medication Claim 2 
    •  - -

    • Benefit coordination: If Prescryptive is providing secondary insurance coverage please disclose amount paid by your primary insurance and include receipt or denial letter from your primary insurance carrier.

    • Medication Claim 3 
    •  - -

    • Benefit coordination: If Prescryptive is providing secondary insurance coverage please disclose amount paid by your primary insurance and include receipt or denial letter from your primary insurance carrier.

    • Medication Claim 4 
    •  - -

    • Benefit coordination: If Prescryptive is providing secondary insurance coverage please disclose amount paid by your primary insurance and include receipt or denial letter from your primary insurance carrier.

    • Upload Receipts (Required) 
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  • Pharmacy Information

  • Please note:

    • Complete and accurate copies of original receipts and printed pharmacy labels for each claim must accompany this form submission. Electronic copies are acceptable.
    • Reimbursement requests will be considered only within 90 days of the prescription purchase.
    • Your claim will be reimbursed based upon your eligibility and plan benefit.
    • Reimbursement will be made to the Primary Member and will be determined based upon the amount paid less applicable benefit co-pays or deductibles.
    • Upon approval, a reimbursement check will be sent within 6-8 weeks of receipt of your request.

     

    Having trouble with this form?

    Click here to download a Reimbursement form.

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