Reimbursement Form for Part D Drugs

Below is a brief description of some of the situations you may submit a paper claim for reimbursement for your Part D drug expenses. For a full description and a complete listing of all situations, refer to the Evidence of Coverage, Chapter 7, asking the plan to pay its share of a bill you have received for covered services or drugs. Some of the situations you may submit a paper claim include:

• When you pay the full cost for a prescription because you don’t have your plan membership card with you.
• When you pay the full cost for a prescription drug that is not on the plan’s List of Covered Drugs (Formulary); or the drug has a requirement or restriction that you didn’t know about or don’t think should apply to you.
• When you use an out-of-network pharmacy to get a prescription filled under one of the following three circumstances:
1. Non-routine situations when a network pharmacy is not available
2. If you are traveling within the United States and territories and you become ill, run out or lose your drugs
3. Prescriptions that are written as part of a medical emergency or urgent care visit.

Please note: you must submit your claim to us within 12 months of the date you received the drug.

When you send us your request for reimbursement, include a copy of your bill and documentation of any payment you have made. It’s a good idea to make a copy of your bill and receipts for your records. Make sure you are giving us all the information we need to make a decision. You don’t have to use our form, but it’s helpful for our plan to process the information faster. Either download a copy of our KelseyCare Advantage Direct Member Reimbursement Form or call Member Services and ask for the KelseyCare Advantage Direct Member Reimbursement Form.