Forms
File for a hassle-free claim reimbursement online
Use our online form to request reimbursement for covered medications purchased at retail cost. Filing online is quick, easy, and results in faster response than filing by mail.
If you would prefer not to file online, download your claim form as a PDF
Medicare and Medicaid forms
- Arizona Medicaid claim form (PDF 71K)
- California Medicaid claim form (PDF 1M)
- Colorado Medicaid claim form (PDF 202K)
- Florida Medicaid claim form (PDF 65K)
- Hawaii Medicaid claim form (PDF 477K)
- Indiana Medicaid claim form (PDF 68K)
- Kansas Medicaid claim form (PDF 63K)
- Louisiana Medicaid claim form (PDF 64K)
- Michigan Medicaid claim form (PDF 164K)
- Nebraska Medicaid claim form (PDF 58K)
- New Jersey Medicaid claim form (PDF 88K)
- New York Medicaid claim form (PDF 174K)
- Ohio Medicaid claim form (PDF 561K)
- Pennsylvania Medicaid claim form (PDF 72K)
- Rhode Island Medicaid claim form (PDF 72K)
- Texas Medicaid claim form (PDF 70K)
- Virginia Medicaid claim form (PDF 274K)
- Washington Medicaid claim form (PDF 119K)
Arkansas prior authorization or exception request
Covid-19 reimbursement
HIPAA and your rights
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you rights over your protected health information (PHI), including the right to obtain, change, share and monitor the information. These rights are collectively known as “Individual Rights.”
Privacy and confidentiality
Authorizing release of your health information
By submitting an Authorization for Release of Information (ROI) form, you can permit someone else to access your protected health information (PHI) or to speak about your medical care on your behalf.
Personal Representative information
By submitting a Personal Representative form, you can legally appoint or designate someone to act on your behalf.