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

Member information

Pharmacy information

Prescription information

Signature

Step 1 of 4

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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

Are you filling this form out for yourself or someone else that is not a Medicare member?

Yes

No, I am the authorized representative for a Medicare member.

Member details

Member first name

Middle Initial

Member last name

Member date of birth

mm/dd/yyyy

Group number

Member ID

Address

Address 2

P.O. boxes are not allowed

City

State

5-digit ZIP code