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Direct member reimbursement form 2026

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The document is a Direct Member Reimbursement Form for the PDP Prescription Drug Plan, which allows members to request reimbursement for covered prescription drugs purchased at retail cost. Members must submit the form along with original receipts within 90 days, ensuring that cash register and credit card receipts are not accepted as proof of purchase. The form requires detailed patient information, prescribing physician details, and specifics about the prescription, including NDC numbers for compound prescriptions. It also includes instructions for submitting claims and emphasizes that reimbursement is not guaranteed.

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Click ‘Get Form’ to open the direct member reimbursement form in the editor.
Begin by filling out the Patient Information section. Enter your Health Plan/Insurance Name, Group Employer/Name, and your personal details including your name, birth date, and I.D. number.
Provide your mailing address, prescribing physician's name, and their DEA or NPI number along with their telephone number.
In the Reason For Request section, clearly state why you are seeking reimbursement.
If applicable, complete the Coordination of Benefits section by providing details from your primary insurance regarding any payments made for the prescription.
For vaccine claims, check all relevant boxes indicating where the vaccine was filled and administered.
If submitting a compound prescription, list each ingredient's valid 11-digit NDC number along with its quantity and total charge paid.
Finally, sign and date the form at the bottom to certify that all information is accurate before submitting it along with your receipts.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is direct member reimbursement?

Depending on your plan, you may have an allowance to help you pay for dental, hearing, vision or other services. We sometimes call this allowance a direct member reimbursement, or DMR.

How do I make a reimbursement form?

There are 2 ways to submit claims online or by mail You will have the option to digitally submit a form or download, print and mail a medical claim form (pdf) to the mailing address found on your member ID card.

What are the three common types of reimbursement?

Member Reimbursement means reimbursement to a Member by the Manager of the Company of any reasonable documented third party legal, tax, accounting or banking costs and expenses directly attributable to the making of its Capital Contribution by a Member to the Company, as determined by the Manager in its reasonable

What is a DMR form?

Information to include on an expense reimbursement form. Name of product or service. Individual item or line cost. Total cost. Payment method (i.e., cash, credit card, etc.) Date purchased. Explanation of purchase. Original or copy of the receipt.

What is a direct member reimbursement?

Use the appropriate Direct Member Reimbursement (DMR) form below to submit a claim to be reimbursed for a prescription you paid out of pocket for at a non-participating pharmacy. For more information visit the Drug benefits and claims FAQs.

dmr form

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