Online Claim Form: UHG, Medicare, PDP, MAPD, Commercial, PPO, Union and Others

Member information
Pharmacy information
Prescription information

Step 1 of 4

Member information

Use this form to request reimbursement for covered medications purchased at retail cost. Complete one form per member.

Include the original pharmacy receipt for each medication (not the register receipt). If you do not have pharmacy receipts, ask your pharmacy to provide them to you. On average, this form takes 10-15 minutes to complete.

Fields marked with an asterisk
are required.

Requestor Information

Member details


P.O. boxes are not allowed