Changing the way you
receive healthcare

  • How to Ask for Reimbursement

    Sometimes when you get prescription drugs, you may need to pay the full cost right away, like if you use an out-of-network pharmacy, don’t have your PHP
    (HMO SNP) member ID card when you fill your prescription, or want a drug that is not our
    or has a requirement or restriction that you didn’t know about or didn’t think applied to you. You can ask us to reimburse (pay you back). It is your right to be
    reimbursed by our plan whenever you have paid for the cost of covered prescription drugs. Save your receipt and
    send us a copy when you ask us to pay you back for our
    share of the cost.

    Please contact Member Services.
    You will need to mail or fax your receipt for the
    prescription drug you purchased to us along with an explanation why you had to pay for the drug on your own. Please be sure you include your name and member ID (found on your member ID card) when you mail or fax your receipt to us.

    By asking for reimbursement for prescription drugs you paid for, you are asking for a
    coverage decision from us. To make this coverage decision, we will check to see if
    the prescription drug you paid for is on our formulary. We will also check to see if you
    followed all the rules for using your coverage for prescription drugs.

    If the prescription drug you paid for is covered and you followed all the rules, we will send you payment within 30 calendar days after we receive your

    If the prescription drug is not covered, or you did not follow all the rules, we will not send payment. Instead, we will send you a letter that says we
    will not pay for the drugs and reasons why.

    If you do not agree with our decision, you can make an appeal.
    We must give you our answer within seven calendar days after we receive your appeal.

    For more information about asking us to reimburse you for services you paid for or pay a provider bill you received, please see Chapter 7 and Chapter 9,
    Section 6 of the 2021 Evidence of
    , or contact Member Services. You may
    contact Member Services to check on the status of your
    request for reimbursement.


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    You will need the Adobe Acrobat Reader program to view the above forms. To download this free program click here or use the link above – the link will open a new window and take you to the Adobe website.

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