Instructions for Completing the Drug Claim Form

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, CVS Caremark 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 CVS Caremark 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 a CVS customer care representative.
  • Representatives are available to serve you 24 hours a day, seven days a week.
  • CVS Caremark provides pharmacy benefit management services and manages HMSA’s drug formulary for HMSA’s commercial, Medicare, and QUEST programs. CVS Caremark is an independent company.