Speak With a Member Services Representative
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:
- Non-routine situations when a network pharmacy is not available
- If you are traveling within the United States and territories and you become ill, run out or lose your drugs
- 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.
Attn: Pharmacy Services
PO Box 841569
Pearland, TX 77584