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Reimbursement request

 

Please enter your member ID and date of birth to get started.

This form is supported on desktop and mobile devices. It takes approximately 10 minutes to complete. In addition to your member ID, you’ll need a clear images of your receipt(s) ready for upload.

 


Please do not use this form for prescription reimbursements.


Instead, download the form ( EnglishEspañol )

 

All fields are required.

Find your member ID number on your ID card, welcome letter or any Explanation of Benefits statement you received from us. Get help locating your member ID.

MM/DD/YYYY

Thank you! Your request for reimbursement has been sent.

Submission date:

 

Here’s what happens next:

 

  • We will start processing your request soon.
  • If you provided your email address, we will send you a confirmation email and status updates about your reimbursement request.
  • It may take up to 30 days from the time we receive all the information until we complete our review.
  • When your request is complete, details can be viewed here.

 

Submission of a claim is not a guarantee of payment, or payment in the full amount. If the services are deemed covered services, then the health plan will reimburse you up to the benefit amount minus any applicable deductibles, coinsurance, or copayments.