| Direct Reimbursement Request

Unable to use your Sav-Rx card at the time of purchase? Direct reimbursement requests can now be submitted electronically

Direct Reimbursement Process

Pay out-of-pocket at Pharmacy
Fill out the form on this screen. Remember to attach a receipt for each claim submitted and explain the reason for not utilizing your Sav-Rx card at the time of purchase
Submit Once submitted, our reimbursement team will review your request and follow-up accordingly

Direct Reimbursement Request

To request direct reimbursement for a claim, please fill out the form below. Be sure to attach images of receipts for each claim

Cardholder Info

Patient Date of Birth

Patient Relation to Cardholder

SelfDependent

Patient Info

Patient Date of Birth (if patient is not cardholder)

Contact Info

Prescription Info

Prescriptions submitted

Out of Pocket Total

Coupon used at time of processing

YesNo

Date of earliest fill

Date of latest fill (if more than one)

Please provide the reason for not utilizing the Sav-Rx card/submitting this reimbursement request

Please upload receipts for all prescriptions along with this form

Note: any receipts submitted to Sav-Rx for reimbursement must include the following:

Patient Name
Date of Service
Drug Name
Drug NDC
Prescription Number
Quantity Dispensed
Amount paid

I have read and accept the terms below

By accepting these terms, you attest that all information is true to the best of your abilities in seeking reimbursement for medications paid out of pocket and/ or that did not adhere to the benefit structure – resulting in a larger amount paid. You also acknowledge that there is no guarantee of reimbursement for medications that may have required a prior authorization or clinical review prior to dispensing the medication(s).

Thank you for your response.
We will contact you soon.

Get ready to flip the script in your best interest!

Direct Reimbursement Request

Direct Reimbursement Process

Direct Reimbursement Request

Cardholder Info

Patient Info

Contact Info

Prescription Info

Thank you for your response.
We will contact you soon.

PHONE INFORMATION

FAX INFORMATION

ADDRESS

Direct Reimbursement Request

Direct Reimbursement Process

Direct Reimbursement Request

Cardholder Info

Patient Info

Contact Info

Prescription Info

Thank you for your response. We will contact you soon.

PHONE INFORMATION

FAX INFORMATION

ADDRESS

Thank you for your response.
We will contact you soon.