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Prescription Reimbursement

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Resources

Prescription Reimbursement

Download the Form


If for some reason you have to get your prescription filled at a pharmacy that does not participate with EHIM, and have to incur an out-of-pocket expense for the entire amount, you may be eligible for partial reimbursement. If you would like to be considered for reimbursement, submit this form, along with the pharmacy receipt (copies are acceptable) to EHIM. The form should be printed, filled out and then faxed or mailed to EHIM. EHIM's fax number is 248-948-9904.

  • Member Information
    • Special Medical Reimbursement Program
    • FSA Management
    • HRA Management
    • Debit Card Program
    • Dental Plan Administration
    • FAQs
  • Downloadable Forms
  • Employer
    • COBRA Event
    • Enrollment or Termination
    • Medicare Part D Forms
  • Member
    • Clinical Medical Release
    • FSA Dependent Care Reimbursement
    • FSA Healthcare Reimbursement
    • HRA Reimbursement Form
    • HRA Rx Reimbursement Form
    • HIPAA Forms
    • Medical Information Release
    • OptumRx Mail Order
    • Prescription Reimbursement
    • Prior Authorization
    • Quantity Limit Medical Necessity PPI
    • Quantity Limit Medical Necessity Request
    • Step Therapy Medical Necessity
    • Walgreens Mail Order Registration
    • Walgreens Mail Order Physician Fax
    • Formulary
  • Pharmacy
    • MAC List Appeal Form
    • TN Standard Pharmacy Reimbursement Form for Actual Cost Appeals

Resources

Prescription Reimbursement

Download the Form


If for some reason you have to get your prescription filled at a pharmacy that does not participate with EHIM, and have to incur an out-of-pocket expense for the entire amount, you may be eligible for partial reimbursement. If you would like to be considered for reimbursement, submit this form, along with the pharmacy receipt (copies are acceptable) to EHIM. The form should be printed, filled out and then faxed or mailed to EHIM. EHIM's fax number is 248-948-9904.


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