PRESCRIPTION CARD

DIRECT MEMBER REIMBURSEMENTS

If for some reason you obtain a prescription that you must pay for and want to submit it for reimbursement based on your covered benefit, you'll need to download and complete the DMR form. Once completed, attach your original pharmacy receipts (showing the drug information) and submit it to the address on the form for processing.

Download a PDF version of the Direct Member Reimbursement form.