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Member NYSUT, AFT, NEA, ALF-CIO

Smithtown Teachers' Association

 President:  Rich Forzano   |   1^st Vice President:  Jane Cassidy   |    2^nd Vice President:   Laura Spencer
Secretary:  Joanne McEnroy     |     Treasurer:  Patty Stoddard
 

Click here for the STA Calendar

Explanation of Reimbursement Forms

Prescription Copay Reimbursement Form Explanation 
Use this form if your situation is similar to the example below:

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.   

If this sounds like it’s the appropriate form for you, then click here for the form.

Drug Claim Form Explanation 
Use this form if your situation is similar to the example below: 

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.

If this sounds like it’s the appropriate form for you, then click here for the form.