Use the Prescription Reimbursement Claim Form to request reimbursement for a prescription drug purchase when:

• You’ve paid in full for the drug and HMSA is either your sole drug plan or your primary drug plan, or
• HMSA is your secondary drug plan carrier and you’ve already received a statement of payment from your primary drug plan carrier.

You must complete a separate claim form for each pharmacy and for each patient.

Submitting the claim form

• To consider reimbursement, HMSA’s pharmacy benefit manager must receive your claim within one year of the date of purchase of the drug(s).
• Keep a copy of the form and receipt(s) for your records.
• Send the completed form to HMSA’s pharmacy benefit manager at the address listed on the second page of the claim form.

Questions about your claim or your HMSA prescription drug coverage

• If you need assistance in completing the claim form, would like to check the status of a claim you already submitted, or have questions about your HMSA drug coverage, please call HMSA Customer Relations and select the Drug option to speak with our pharmacy benefit manager’s customer care representative.
• Representatives are available to serve you 24 hours a day, seven days a week.