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Detailed information must be provided when you submit a manual claim. By following the instructions below, your claim will be processed without delay.

How to file a Manual Claim
  1. Select the proper claim form below:
  2. Complete all the information on the form. Please note: forms missing information are returned without payment.
  3. Sign and date the Certification Statement.
  4. Submit a separate form for each family member.
  5. If the member has other insurance coverage, attach a copy of the "Explanations of Benefits" or "Denial Notification" from the primary insurance carrier.
  6. Keep a copy for your records. Documents submitted will not be returned.
  7. Mail or fax the claim form and the original receipt for processing. The mailing address and fax number are listed on the claim form.

Call Customer Care at the toll-free number found on your pharmacy benefit member ID card for further questions.