Universal claim form: Fill out & sign online

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Click ‘Get Form’ to open the CVS Caremark Prescription Reimbursement Claim Form in the editor.
Begin by filling out the Card Holder/Patient Information section. Ensure you include the Identification Number from your prescription card, Group No./Name, and complete all fields for both the cardholder and patient details.
Next, provide Other Insurance Information if applicable. Indicate whether any medicines are for an on-the-job injury and if they are covered under another group insurance. If so, specify if it is Primary or Secondary coverage.
Include all original pharmacy receipts as required for processing your claim. Ensure that each receipt contains necessary details such as Patient Name, Prescription Number, and Total Charge.
Finally, sign and date the form to certify that all information is accurate before submitting it according to the provided mailing instructions.

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