Manual Claims

To submit a claim, please enter the required fields below. For help, please call customer support at +1 (800) 710-9341.

Member First Name

Member Last Name

Member ID

Date Of Birth

Sex

Group ID

Primary Cardholder First Name

Primary Cardholder Last Name

Relationship

Phone

Address Line 1

Address Line 2

City

State

Zip Code

Rx Number	Quantity	Day Supply	Amount Paid	Claim Date	File

Disclaimer

The submission of this Rx Claim form, for you and/or dependents, authorizes the release of all information to the Plan Sponsor, Administrator, and/or Pharmacy Benefit Manager.

I Accept

Certification

I certify that the information on this form is correct. I also confirm that the patient, for whom this claim is made, had coverage at the time the claim was incurred.

I Accept