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Employee Health Care Plan – Prescription Drug Request for Reimbursement
Reimbursement for Prescription Drug Benefits not Processed by Pharmacy

If you visited a non-participating pharmacy or purchased your prescription without your Health Plan Identification Card and paid the full cost of your prescription, you will need to do the following in order to obtain reimbursement:

  • Complete CVS Caremark's Prescription Reimbursement Claim Form located at https://www.advancerx.com/ms/content/standard.pdf

    • Complete only the Insured Information section with the secondary cardholder's information and the Patient Information section
    • If all necessary information is included on the receipt (including days supply), you do not need to complete the Prescription Claim Information section; however, if any of the information is missing on the receipt, please provide it in the Prescription Claim Information section
    • The pharmacist does not need to sign the form if all information is provided (form asks for pharmacist's signature, but not needed)
  • Send the completed form with your prescription receipts to the address on the bottom of the form
  • Keep a copy of the form and your original receipts for your records
  • If you have any questions, please contact:

    University Benefits Department (801) 581-7447
    CVS Caremark Customer Care Department (800) 966-5772

Coordination of Prescription Drug Benefits Reimbursement Process
If you are eligible for Coordination of Prescription Drug Benefits and paid your coinsurance amount, you will need to do the following in order to obtain reimbursement:

  • Complete the CVS Caremark Standard Claim Form: https://www.advancerx.com/ms/content/standard.pdf  

    • Complete only the Insured Information section with the secondary cardholder's information (the card that was not originally used to purchase the prescription) and the Patient Information section.
    • Attach the receipt for the prescription purchased. If all necessary information is included on the receipt (including days supply), you do not need to complete the Prescription Claim Information section; however, if any of the information is missing on the receipt, please provide it in the Prescription Claim Information section.
    • The pharmacist does not need to sign the form if all information is provided (form asks for pharmacist's signature, but not needed).
  • Please keep a copy of the Claim Form and your original receipts for your records.
  • If you have any questions, please contact:

    University Benefits Department (801) 581-7447
  • Complete the Coordination of Prescription Benefits Claim Form
  • Send the completed forms with your prescription receipt(s) to the following address:

CVS Caremark
Attention: Chad Madden, Client Advocate
9501 East Shea Boulevard
Mail Code 005
Scottsdale, AZ 85260-6719

  • Keep a copy of the forms and your original receipts for your records
  • If you have any questions, please contact:

    University Benefits Department (801) 581-7447
    CVS Caremark Customer Care Department (800) 966-5772

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