Example of someone who would need this form:

You work for Smithtown and are enrolled in the SSEHP Family Plan administered by United Healthcare. Your spouse works somewhere else and has the Empire plan (or some other health insurance plan including SSEHP). Your spouse goes to get a prescription filled for him/herself, so it gets processed under that plan. Suppose that other plan has a $50 copay. Your spouse can get the pharmacy receipt (not the cash register receipt) and submit it, with this form, to United Healthcare and your spouse will get reimbursed for the entire $50.

 

Drug Claim Form

Example of someone who would need this form:

You go to a pharmacy you've never been to before so your information is not on file. You forgot your UHC card, but really need the medication right there and then. You decide to pay the $175 for the medication. You would now submit the pharmacy receipt (not the cash register receipt) along with this form to Medco for reimbursement for your in-store cost minus the appropriate copay.