Prescription Drug Reimbursement Claim Form

A claim form can be used:

1. During the period between the effective date of your prescription plan and the receipt of your prescription card.
2. When prescription drugs are purchased at a non-participating pharmacy.
3. When traveling out of town without your prescription card and reimbursement is needed for prescription drugs purchased.

If you need a Prescription Drug Claim Form, click here to see the detail, print a form out, complete it, and send it to:

GS-POPS
PATIENT REIMBURSEMENT
P.O.BOX 4190
Hamilton, NJ 08610