Prescription Reimbursement Claim Form

Now, there are two ways to submit a claim form:

Complete and submit the form online. It's a secure and quick way to submit your claim. Log in to get started.

or

Download the form and mail it to us. Follow these links or log in to find the form.

• Express Scripts members: download the form here.
• TRICARE beneficiaries: download the form here.
• Medicare Part D members: download the form here.

Login

Log In

Don't have an account? Register now